PATIENT FINANCIAL RESPONSIBILITY STATEMENT

Thank you for choosing PrimeCare of Coral Gables as your healthcare provider. The medical services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive.

By signing below and/or by receiving medical services from PrimeCare of Coral Gables you agree:

• You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services.
• You are responsible for deductibles, co-payments, coinsurance amounts or any other patient responsibility indicated by your insurance carrier which are not otherwise covered by supplemental insurance.
• We are NOT responsible for Laboratory tests not covered by your insurance company. If you have not met your annual deductible, some of your lab costs could be applied to your deductible. Some insurance companies require co-payments for Lab Tests. If you have questions, please contact your insurance carrier. Doctors do not know what is covered under your plan.
• You are responsible for knowing your insurance policy. If you are not familiar with your plan coverage, we recommend you contact your insurance carrier.

Waiver of Patient Authorizations

I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and to submit claims to insurance at my discretion.

ONCE I HAVE SIGNED THIS AGREEMENT, WHETHER BY ORIGINAL, FACSIMILE OR ELECTRONIC (“.PDF”) SIGNATURE, I AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN AND THE AGREEMENT SHALL BE IN FULL FORCE AND EFFECT.