Body-Mind-Spirit Podiatric Center
INSURANCE - Please give your insurance forms, cards and driver’s license or identification card to the receptionist to copy.
I/We hereby name the Doctor and/or Medical Practice given below, hereafter referred to as DOCTOR, as my/our assignee. I/We instruct my/our health care benefits plan administrator, i.e.: insurance company, HMO, employer or government benefits provider, hereafter referred to as the PLAN, to pay the DOCTOR directly for all professional and medical services provided by the DOCTOR, through the means of electronic funds transfer (EFT) or by check(s) made payable to and mailed to the DOCTOR:
REMIT TO: Body-Mind-Spirit Podiatric Center, PLLC Brian K. Bailey, DPM 500 14th Street Ashland, Kentucky 41101 or if my current policy prohibits direct payment to doctors, then I/we hereby instruct and direct the PLAN to make out all checks payable to me/us and mail the payments to me/us in care of DOCTOR as given directly above.
THIS IS A DIRECT ASSIGNMENT OF MY/OUR RIGHTS AND BENEFITS UNDER THIS POLICY. I/We grant the DOCTOR a limited Power of Attorney to sign my/our name(s) in order to deposit and negotiate any payment received from the PLAN and apply the funds received toward my/our outstanding balance. These payments will not exceed my/our indebtedness to the above designated DOCTOR. I/We agree to promptly pay any remaining balance due on all professional service charges over and above payment(s) from the PLAN. This Assignment shall remain in effect until canceled in writing by the DOCTOR.
A photocopy of this agreement or an electronic facsimile thereof, shall be considered as effective as the original. I/We understand that additional information about me/us will be needed by the DOCTOR and the PLAN to determine and communicate what services or benefits are covered by the PLAN and to submit or process a claim for payment on services rendered and for the DOCTOR to collect all fees owed for those services rendered. I/We give the DOCTOR and the PLAN the Health Care Financing Administration, their agents, and/or any other holder of information above me/us authorization to release and/or exchange medical billing and collection information.
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.
The Responsible Parties whose signatures appear below agree as follows: The Doctor(s), and staff of the Medical Practice, BODY-MIND-SPIRIT PODIATRIC CENTER, named on this form and hereafter referred to as DOCTOR are authorized to medically treat the patient named on this form. Doctor is authorized to collect, use and exchange individually identifiable health information consisting of the patient’s past, present and future medical information and other personal information to treat the patient, communicate with the patient’s other physicians and medical care givers for the purpose of enhancing the continuity of care for the patient. The Responsible Parties agree to pay for all fees and charges for supplies, services and treatment incurred by the patient per terms of this agreement and authorize a DOCTOR or agents thereof to make credit investigations including employment verifications, all charges shown on billing statements are agreed correct and reasonable unless disputed in writing within thirty (30) days of the billing date. The Responsible Parties remain jointly and severally financially responsible for the patient until the DOCTOR received their notification in writing to the contrary. If the patient is currently a minor, their guarantee is continuing even after the patient reaches the age of majority. Not all services and/all fees are covered or paid by the Responsible Parties’ HEALTH PLAN. Therefore, the Responsible Parties agree to pay for all deductibles, co-payments, non-covered services and any portion of covered services not paid in full by the PLAN and understand that such payments are due at the time of service or immediately upon presentation of the bill. All proceeds from the PLAN are assigned to the DOCTOR where applicable. Payments to the DOCTOR may not be withheld, delayed or excused for any reason including the outcome of medical treatment, liens, lawsuits, any coverage determination by the PLAN or their processing of claims, financial insolvency of the PLAN and/or their contracted intermediaries & medical groups. Responsible Parties are strongly advised to monitor and communicate with the PLAN to ensure that DOCTOR’S Claims are paid promptly, since they are Responsible Parties are ultimately financially responsible for all amounts owed to DOCTOR. If any account balance is not paid in full within sixty (60) days the entire account balance will be subject to a MONTHLY FINANCE CHARGE and a MONTHLY COST OF RE-BILLING/ACCOUNT MAINTENANCE CHARGE at rates listed previously on the reverse side of this form. These rates and changes are subject to change upon thirty (30) days written notice. If any account balance shall remain unpaid for sixty (60) days and the DOCTOR refers to the account to a collection agency or attorney for collection, the Responsible Parties agree to pay the cost of collection and that such fees and costs may be added to the account balance. In a legal action between the parties to this agreement to collect an unpaid balance due for medical services rendered, the prevailing party shall be entitled to recover reasonable attorney’s fee and costs. Payments will not be delayed or withheld, regardless of any lawsuits, liens, insurance coverage, dependency of claims thereon or the outcome of treatment. All proceeds from the PLAN are assigned to the DOCTOR where applicable. As they are responsible for all charges the Responsible Parties will assist the DOCTOR in every way to collect payments from the PLAN to the extent their help is required. The Responsible Parties acknowledge receipt of the DOCTOR’S office policy that includes the terms of this financial agreement and authorization for treatment. This form together with the DOCTOR’S office policy contain the entire and only agreements between the parties. There are no other agreements, promises, representations, or warranties, expressed or implied. The provisions of these agreements shall not be changed or modified except for an instrument in writing signed by the parties hereto.
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