PAYMENT POLICY FOR SERVICES RENDERED

• If You Have Health Insurance: Please Initial the Line Next Your Insurance in Section 1, 2 Or 3.
• If You Do Not Have Health Insurance: Please Read Section 4.
• Everyone: Please Sign at Bottom of Form and give your card (if applicable) to the Receptionist so we may make a copy for your file.

1. IF YOU HAVE INSURANCE WITH ONE OF THE FOLLOWING INSURANCE COMPANIES, please initial the appropriate line. We will bill these companies directly and will follow up on outstanding balances. You will be responsible for payment of your designated co-pay at each visit to the office BEFORE you see the doctor. You are responsible to present updated referral authorizations from your insurance carrier when required.

2. IF YOU HAVE BEEN INJURED ON THE JOB AND YOUR EMPLOYER HAS WORKERS COMPENSATION COVERAGE, we must have information approving the claim from your employer and an accurate billing address to send the claim to for processing. Without this, we will consider payment for this visit to be your responsibility. Hudson Valley Pain Management follows the New York State Workers Compensation fee schedule and is not a member of any Worker’s Comp PPO’s.

3. IF YOU HAVE COVERAGE WITH INSURANCE COMPANY, NOT LISTED ABOVE. If you provide us with a copy of your card, we will submit a claim directly to your insurance company for reimbursement as a courtesy. I understand that this entire balance is at all times my responsibility.”

4. IF YOU DO NOT HAVE HEALTH INSURANCE, you are responsible for payment of your bill at the time of your visit. We accept personal checks, credit cards, and cash. A payment of $50.00 is due before your visit. The balance will be due when your visit is complete. If your bill exceeds $200.00, a payment plan can be worked out at the time of the visit. Please ask for our payment agreement form.

"I understand and agree that regardless of my insurance coverage, I am responsible for the balance of this account for any professional services rendered. I certify that the above information is true and correct to the best of my knowledge. I will notify the office of any changes in my insurance status. I also agree that if I am unable to pay my bill promptly, I will call the billing department to make timely payment arrangements. I understand that if my account becomes delinquent and Hudson Valley Pain Management incurs any collection charges, they will be my responsibility.”

If the patient is a minor: “By consenting to care at Hudson Valley Pain Management I am agreeing that I will take responsibility for the payment of the medical bills. I will provide the office with all information necessary and will communicate with the office regarding any changes in responsibility.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application