Acknowledgement of Financial Policy

GILLESPIE COUNTY UROLOGY

Please correct the errors described below.

Please read the following and initial in the space provided to acknowledge your understanding of Michael C. Speck, M.D., P.A. financial policy.

I understand that the office will copy my insurance and driver’s license. It is my responsibility to notify the office of an insurance coverage change.

I understand that payment of copayments, deductible, and percentages not covered by my insurance carrier are due at the time services are rendered.

I understand that a $30 service fee will be applied to all returned checks.

I understand that I am responsible to know my insurance benefits and that I am responsible for any balance not covered in my explanation of benefits.

I understand that Michael C. Speck, M.D., P.A. is a Medicare provider and will submit all claims to them. If I am a Medicare recipient, I know I will be responsible for annual deductibles, 20% coinsurance, and any charges the Medicare states that I am responsible for.

I understand that Michael C. Speck, M.D., P.A. requires 24-hour cancellation/rescheduling appointment notice and a charge of $25.00 and $50.00 will apply for office visits and procedures without proper notice.

I understand that ultimately it is my responsibility to obtain any necessary referrals if my insurance carrier requires one to see a specialist. Also, that if a proper referral is not obtained by the time services are rendered, I will be financially responsible for those services upon checkout.

INSURANCE BILLING:

I hereby authorize Michael C. Speck, M.D., P.A. to furnish my insurance company with all the information that they may request concerning my present illness or injury. I assign Michael C. Speck, M.D., P.A. all money to which I am entitled for medical expenses related to the service reported. I understand that I am financially responsible to Michael C. Speck, M.D., P.A. for charges not covered by this assignment.

All Information that I have provided pertaining to my account is accurate and true to the best of my knowledge.

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.

If you have questions about your insurance coverage, please call us at 830-304-1665 during regular office hours.

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