Patient Financial Policy and Final Obligation Form

We are dedicated to providing the best possible care and service to you, and regard your complete understanding of our financial policies as an essential element of your care and treatment. If you have any questions, please discuss them with our staff

Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for the payment.

Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept Visa, Master Card, Cash or Checks.

As our patient, you are responsible for all authorizations/ referrals needed to seek treatment in this office.

If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send a claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your -care and treatment are due at the time of services.

All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "NOT COVERED," or you do not have authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any services rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

You must inform the office of all insurance changes and authorization/referral requirement. In the event the office is not informed, you will be responsible for all charges denied.

For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.

There are certain surgical procedures that we require prepayment. You will be informed in advance if your procedure is one of those. In that event, payment arrangements can be made.

Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due to this office.

There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee.

Financial and Insurance Authorizations

If Dr. Jennifer Fung- Schwartz (The Office) participates in my health insurance plan, the office will submit the bills to the insurance company and will be paid directly by them. I will be financially responsible for any required deductibles and co-payments. In the event that a service is provided to me, which my health insurance plan determines to be not covered by my policy, or I have not obtained the required prior authorization for the service or visit, I will be responsible for the total charge.

I authorize that all payments of financial benefits for professional services rendered be made to Dr. Jennifer Fung- Schwartz, DPM.

I authorize the relase of any medical information necessary to process any insurance claim or laboratory testing.

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.