Amory de Roulet, MD MPH | VI Medical & Surgical Associates, LLC
All information contained in this questionnaire is strictly confidential and will become part of your medical record.
This agreement is between VI Medical & Surgical Associates, LLC (VIMSA – the provider of medical service) and the patient who is receiving medical services or the Responsible Party for minor patients (those patients under 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills. By executing this agreement, you are agreeing to pay for all services that are received.
It is your responsibility to know the requirements of your insurance company. This includes participation, referral requirements, second opinion, prior approval, pre-certification and out-patient and/or in-patient status. You are also responsible for all co-payments, co-insurance and insurance deductible as required by your insurance plan. You must be aware of any pre-existing wait period or waiting periods outlined by your insurance carrier.
If you have a balance on your account, we will send you a monthly statement. It will show current balance and insurance adjustments/payments. Unless VIMSA, LLC approves other arrangements in writing, the balance in full on your account is due and payable within 60 days from the date of service.
Insurance is a contract between you and your insurance company. We are not party to this contract in most cases. We gladly submit your claims and will assist you in receiving the maximum benefit from your plan. All plans, however, have limitations and some may not cover 100% of the fees for our service. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in lower payment from the insurance company.
Payment is required in full from the date of service, unless other arrangements have been made, in writing, with VIMSA. Past due accounts If your account becomes past due, we will take necessary steps to collect this debt, which could result in turning your account over to a collection agency or attorney.
Once you have signed this agreement, you agree to all of the terms and conditions contained herin and the agreement will be in full force and effect.
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