P.O. Box 961094, File 916211, Fort Worth, Texas 76161-1094
As we enter this doctor-patient relationship, we agree to provide quality healthcare care at a fair and reasonable price,
and you in turn, agree it is your obligation to be prepared to pay at the time of service and to understand the benefits of
your insurance. We want to explain our financial policy to you so there are no unpleasant surprises.
• Co-payments, deductibles and/or coinsurance are due at the time of service.
We accept Cash, Personal Check,
MasterCard, Visa, Discover and American Express. If you are not prepared to pay at the time of service, we are happy to reschedule the appointment to a better time. The estimated financial responsibility for scheduled services will be due prior to these services being provided. Any remaining balance after your health plan pays will be due upon receipt of a statement. If insurance coverage cannot be verified prior to the appointment, the account will be notated as private pay and payment will be due in full. Account balances over 90 days with no payment activity will be reported to the credit bureau(s). Any payment arrangements must be made prior to time of services.
• Your insurance policy is a contract between you and your insurer. It is your responsibility to know what your policy covers and what it does not although we will help you get the most out of your benefits.
We cannot quote your benefits. Any item deemed "non-covered" by your insurance carrier will be your financial responsibility. We do not accept 'usual and customary' payments. Any disputes about payment must be resolved between you and your insurance carrier. This also includes lab designation and payment disputes. You are responsible for ensuring a properly dated referral and/or authorization if required by your insurer for services being provided. It is your responsibility to make certain you have subsequent authorizations during ongoing treatment. You are also responsible for payment if your claim denies for lack of referral/authorization.
• As a courtesy to you, we will file primary and secondary participating insurance for you with proper payment assignment within 3 business days of your appointment. Please bring your primary and secondary insurance card with you to every visit and provide the front desk with any updated information at check-in. I understand that all remaining balances are my responsibility to satisfy prior to additional services being rendered.
• This office is not party to legal disputes/agreements. The financial responsibility rests with the patient.
• A $35.00 fee will be assessed for all returned checks.
• Payments & credits are applied to the oldest charges first, except for insurance payments, which are applied to the
corresponding dates of service. Refunds over $50 will be provided within 30 days from the date all outstanding claims
are satisfied. Any credit balance less than $50 will be available and processed upon request of the patient.
Assignment of Benefits
,request payment of the medical benefits, otherwise payable to me, directly to Fort Worth Perinatal Associates, PA for
services provided to me by them.
I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and
agree that such terms may be amended by the practice at any time.
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.