Appointment and Insurance Coverage Policy Form

Please correct the errors described below.

Attention Patient/ Responsible Party:

Insured Party: You are responsible for any referrals or authorization numbers from your Primary Care Physician (PCP). Please ensure your PCP faxes this information to our office prior to your scheduled appoinment or bring the referral/ authorization number with you to your appointment. If no referral, authorization number, or insurance is available at the time of your appointment, you have the option to pay in full at the time of service. You may also reschedule your appointment to a later date. There will be no exceptions granted. If you elect to pay out-of-pocket please be advised that Panda Pediatrics and Adolescent Care will not submit a claim to your insurance carrier for that particular date of service and all monies will be forfeited and not reimbursed. Private Pay Patients: You are responsible for full payment of services on the date the services are rendered. If you wish to inquire about payment plans, please contact our Billing Department at 602-283-3606. Payment arrangements need to be made prior to appointment. We accept p Despues de la tercer cita que no asista, tenemos el derecho de sacarle de nuestro practica medica por no seguir instrucciones del medico.ersonal checks imprinted with your name, current address, and phone number. We also require your driver's license and / or credit card information. We accept cash, Visa, Mastercard, Discover, with the exception of American Express, as well. Please Note: There is a $25.00 charge for missed appointments and a $75.00 charge for missed procedures, if we do not receive notice at least one business day prior to your appointment. Remember you are responsible for keeping your own appointment whether or not our office or hospital contacts you to remind you. After the 3rd missed appointment, we reserve the right to dismiss you from our practice for failing to comply with our physician's medical recommendations. You are responsible for any outstanding balances not covered by your insurance carrier. Insurance carriers state repeatedly that coverage and /or authorization is not a guarantee of payment. In the event it becomes necessary to turn your account over to an outside collection agency, you are responsible for all fees associated with recovery, including (but not limited to) collection agency fees, attorney fees, and court fees. PANDA PEDIATRICS AND ADOLESCENT CARE RESERVES THE RIGHT TO DENY SERVICES TO ANY PERSON WHOM FAILS TO COMPLY WITH THE ABOVE INFORMATION. I read and agree to the above information. I understand that I am responsible for obtaining my referral/authorization number prior to my appointment and that I am responsible for full payment for services rendered that day. I also understand that I am fully responsible for any outstanding balances not covered by my insurance carrier. Finally, I understand that if my account is referred to an outside collection agency, I will pay all collection agency, attorney, and court fees.

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Atencion Pacientes/Personas responsables:

Paciente con aseguranza o parientes del paciente: Usted es responsable de obtener referidos y autorizacion de su doctor primario primeramente. Por favor, segurase que su doctor primario alla enviado todo su informacion antes de la cita o favor de traer su referido o autorizacion a su cita. Si no tiene un referido o numero de autorizacion valido al tiempo de la cita usted tiene la opcion de pagar el monto total al tiempo que se le da servicion o puede hacer otra cita para despues. Si usted paga por su servicio la compania de aseguranza le rembolsara el dinero que gasto posiblemente. Paciente Sin Aseguranza: Seria responsable de pagar el monto todo por sus servicios al tiempo de la cita. Si usted desea hacer un plan de pagos llama a nuestro departamento de Financias al 602-283-3165 por lo menas una dia antes de la cita. Aceptamos sus personales impresos con su nombre direccion y telefono. Tambien requerirmos una forma de indentificacion o una tarjeta de credito. Nota: Hay un cargo de $25.00 por citas no acudidas y hay un cargo de $75.00 si falta a cualquier procedimiento medico si no recibimos un aviso por los menos un dia anterior a su cita. Recuerde que usted es responsable por acudir a sus citas, NO es la responsabilidad de nuestra oficina o del hospital llamarle para recordarle de su cita. Duspues de la tercera visita faltado tenemos el derecho de terminar el cuidado del paciente en caso de incumplimiento con la recomendacion medica del medico. Seria usted responsable por caulquier balancia que no sea cubierto por su aseguranza. A tener la autorizacion or referido de su aseguranza no se garantiza el pago del servicio. Si vemos la necesidad de mandar su cuenta a una agencia de coleccion, usted seria responsable de pagar los cargos de abogado y del corte. Panda Pediatrics and Adolescent Care reserva el derecho de negar servicio aquell persona que no este de acuerdo con la informacion antes dicha.

DISCLAIMER: 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. DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud de manera electrónica. Usted acepta que su firma electrónica es el equivalente legal de su firma manual en esta solicitud.

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