Patient Eligibility & Financial Responsibility Form

Please correct the errors described below.

The purpose of this form is to help our patients understand about medical insurance, eligibility, coverage, our office policy and medical services. It must be understood that:

  • We render our services on the basis that insurance companies may or may not pay for all, or a portion of our charges.
  • Authorizations for medical treatment from your insurance company/doctor do not guarantee full payment for the service.
  • Not all insurance companies/third party payors pay for all services, each policy has its own particular stipulations regarding covered services, or amount of coverage.
  • All insurance companies state that verification of coverage is not a guarantee of coverage or payment. Actual benefits are determined by your insurance company after a claim is received.
  • Patients are personally responsible for Knowing and Understanding their own Insurance Policy, Eligibility and Coverage.
  • Patients are responsible for payment of outstanding Deductibles and Co-insurance amounts at time of service. Co-payments will be collected at the time of service.
  • Patients are financially responsible for payments of all non-authorized procedures and non-covered services.
  • Any appointment missed or not cancelled more than 24 hours in advance will incur a $50.00 charge.
  • Returned checks are subject to a $35.00 fee.
  • Changes in insurance coverage must be reported to our staff promptly to avoid financial responsibility.

The Patient or Patient's Legal Representative hereby acknowledges that he/she is Eligible for Health Insurance Benefits and Coverage. That in the event of ineligibility for coverage of plan benefits, as well as all non-authorized procedures and non-covered services, he/she understands and agrees to be fully financially responsible for payment of all costs incurred during the delivery of health services, and agrees to pay all charges to the Physician accordingly.

Your message will be encrypted.