I hereby assign, transfer, and set over to Texas Ear and Vestibular Institute all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. All deductibles and copays are due at the time services are rendered and will be collected based on the information provided by your insurance company. I understand that charges not covered by my insurance company or my secondary insurance if applicable, as well as any applicable co-payments, coinsurance, and deductibles are my responsibility. If your insurance is with an HMO or other managed care program, Texas Ear and Vestibular will bill them only if you present an appropriate authorization form. If you do not have an appropriate authorization form for each visit, you will be responsible for all charges during that visit. If your insurance company has not paid your account in 90 days, the balance may be transferred to you for payment.
I understand that if I default on payment for services, my account may be transferred to an independent collection agency, designated as credit risk and payment for services will be required at the time of registration for all future visits. I have read the financial policy as above. I understand and agree to above financial policy.
We currently accept cash, Visa, Mastercard, Discover, American Express and Care Credit. Unfortunately, we are not accepting checks currently. If you have any questions regarding your bill, please contact our billing department at 469-625-2879.