Genetic Counseling Billing Form

Please correct the errors described below.

Patient Information

PARTNER INFORMATION (if the patient is pregnant, then "partner" is the father of the pregnancy)

Client Information

Fort Worth Perinatal Associates | Client/Sub Client #s: 3204961320497

Billing Insurance Information / Informacion De Seguro Para Cobro

(Complete Section 1 if you are paying by cash OR Section 2 to have your insurance company billed.) (Lienar Sección 1 si pago es en dinero efectivo. Lienar Sección 2 si quiere que su cuenta sea enviada a su seguro medico

Section 1

Medicare: (Copy of card required/Copia de la tarjeta)

*Do not attach credit card Information to this form

SECTION 2: Copy of Insurance card (front & back) required, attach copy of authorization If available. Copia de Ia tarjeta del seguro (parte delantera y posterior), adjuntar copia de Ia autorizacion si está disponible.

Non-authorized services will be billed to the patient. | Servicios no autorizados serán cobrados a Usted.

English

The charge for these services is separate from any other tests or procedures. I authorize Integrated Genetics to furnish my designated insurance carrier any information concerning my services that is necessary for reimbursement. I also authorize benefits to be payable to Integrated Genetics. I understand that I am responsible for any amount not paid by insurance. Many insurance carriers will pay only for services they deem to be reasonable and necessary or a covered service. If my insurance carrier determines that a particular service is not reasonable and necessary, my insurance carrier may deny payment. If my plan does not cover the genetic counseling or medical consult provided by Integrated Genetics, I agree to be responsible for full payment

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.

Español

El cobro de estos servicios son aparte de cualquier otro examen o procedimiento. Yo autorizo que Integrated Genetics supla a mi seguro medico de cualquier información que sea necesaria para reembolso. Yo tambien autorizo que los beneficios sean pagados a Integrated Genetics. Yo entiendo que sat responsable por cualquier cantidad que no sea pagada por mi seguro medico. Muchos seguros medicos solamente pagan por servicios que consideran razonables o necesarios. Si mi seguro detennina que algun servicio en particular no es considerado razonable o necesario, mi seguro medico puede negar pago. Si mi plan no cubre Ia charla con Ia consejera genetica o consulta medica provista por Integrated Genetics, yo accedo hacenne responsable porIa cuenta en complete.

Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Usted acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.

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