IN -NETWORK/OUT OF NETWORK AND/OR PRIVATE INDEMNITY INSURANCE ALLOWANCE AGREEMENT:
I fully understand that, even though I have a referral authorization from my primary care physician, if my carrier deems that the visit/or procedure is cosmetic or not medically necessary, I will accept full responsibility for payment to Dr. Gilberto Alvarez del Manzano.
In addition, should my carrier deny payment due to the fact that I have a pre-existing condition, I will accept full responsibility for payment. Accepting your insurance allowance means that you are responsible for the payment of all deductible and co-insurance(s), if applicable, which is the difference between the insurance carrier approved/allowed amount and the paid amount. Each individual may have an annual deductible amount that must be satisfied prior to the insurance benefits commencing. If my insurance carrier determines that the visit/procedure is deemed cosmetic or not medically necessary, I will accept full responsibility for payment. In conclusion, should my carrier deny payment due to the fact that I have a pre-existing condition, I will accept full responsibility for payment of the charges outstanding.
ALL PATIENTS PLEASE READ AND SIGN THE FOLLOWING:
If I have unknowingly provided the incorrect information, such as the primary carrier, effective date of coverage or I have not provided your office with the necessary identification card and for referral authorization at the time services are rendered, I agree to be fully responsible for the charges incurred. Furthermore, if it is later ascertained that I am insured by a carrier of which you are not a participating provider, I understand that I will only be reimbursed the insurance payment issued and not the charges I have incurred and paid.
I authorize the release of any information necessary to process my insurance claim. I request that payment be made directly to the physician for services rendered. A copy of this authorization may be used in place of the original. This is also an authorization for the doctor to take, or direct to be taken, any photograph(s) required for the completion or records. These photographs shall be the sole property of Dr. Alvarez del Manzano and may be used for educational or promotional purposes. It is also understood that these photographs may be used in medical or lay publications or shown at scientific meetings. The patient's identity will be concealed.
I am aware that the office policy states that I must notify the office at least 24hrs in advance, should I need to reschedule my appointment. In the event that I do not call or email the office within 24hrs of my scheduled appointment or I simply do not show, I understand that I will be billed $25* for an office visit and $50 for cosmetic/aesthetic or procedure appointments. I agree that I will accept full responsibility for this charges and payments for appointments not cancelled 24hrs in advance.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.