Billing Summary / Benefits Policy

Our office will accept an assignment of benefits from your insurance company with the following provisions:

1. Filing claims through insurance does not eliminate the financial obligation for the medical service my
child or I have received.

2. Copay, deductible and coinsurance amounts are due in full at the time of service. We do not waive
collection of these fees in exchange for medical services. Payment of any remaining balance is due after
your insurance company processes the claim or as provided below.

3. If we have not received payment after 90 days, we will charge the credit card we have on file OR we will forward the balance to a third-party collection agency.

4. If your claim is denied, you will be responsible for paying the self-pay or cash balance plus full
cost of all medical supplies.

5. Our office will NOT enter into a dispute with your insurance company for any claim, although we will
provide necessary documentation your insurance company requests to sort out any confusion or
questions that may arise. We will cooperate fully with the regulations and requests of your insurance
company. It is ultimately your responsibility to resolve any type of dispute over payments made or not
made by your insurance company.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY HEALTH BENEFITS DIRECTLY TO THE OFFICE OF JULIE TOMBERLIN MD PA.

DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.