Authorization and Agreements of Medical Treatment Insurance Benefits and Financial Responsibility

CONSENT FOR EXAMINATION: I understand that medical treatment may be necessary for the patient by My Kid's Doc Southfield, P.L.L.C., or his associates or assistants.

I understand the examination procedures will be explained to me and I shall consent to the partial or complete examination. I understand that the examination results will be provided to me with recommendations. The responsibility for any follow-up examinations to check abnormalities found and treated lies with me and not with my physician. I hereby release my examiner from all responsibility in connection with this examination.

CONSENT FOR TREATMENT: I understand that medical treatment is necessary for the patient by My Kid's Doc Southfield, P.L.L.C., or his associates or assistants. I hereby consent to and authorize the administration of all diagnostic and therapeutic treatments that may be considered advisable or necessary in the judgment of the physician. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments.

1. Payment is due at the time of service. We accept cash, checks, and credit cards.
2. All co-payments, deductibles and non-covered services must be paid in full at the time of service.
3. A schedule of fees for our services is available at the reception desk. Our office will submit claims to your insurance company as a service to you. It is important that you know what your insurance plan covers. Services not covered by your insurance are your responsibility.
4. If your insurance company requires laboratory specimens to be sent to a specific lab, it is your responsibility to know the participating lab. Please make us aware of the plan requirements.
5. If your insurance is a managed care plan please review your coverage. If you require services that require a referral -adequate planning is essential. Referrals must be authorized by your doctor and usually require an office visit. Authorization from managed care plans for your referrals may take one or more days. Please be aware that we are often unable to accommodate call-in requests for referrals. Do not expect our office staff to obtain your referral forms -this is your responsibility. Failure to obtain necessary authorizations often lead to out of the pocket expense. We are happy to assist you in any way with your managed care plan however our experience with these plans has demonstrated that planning and adequate lead time are essential. Your knowledge of your plan regulations and benefits as well as adequate planning will help avoid delays and denied claims.
6. In the case of estranged or divorced parents, the parent accompanying the child to the visit is responsible to pay for services rendered -regardless of coverage arrangements. We will gladly furnish you with the necessary statements for reimbursement.
7. Your doctor is here to manage your medical care. The physicians are not experts on insurance and cannot be aware of all financial arrangements. Please discuss insurance problems and financial arrangements with the business office staff.
8. If you are experiencing financial difficulties please discuss this with the business office staff. We will gladly work with you to make payment arrangements. Accounts over 90 days past due may be referred to a collection agency.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.