RESPONSIBILITY FOR PAYMENT: I understand that I am personally financially responsible to CW and Practice Management Services for charges I have incurred that are not covered by the assignment of benefits.
PAYMENT @ TIME OF SERVICE (self-pay):
I understand that I am required to pay a 20% deposit on my charges at the time of services unless I have a medical insurance carrier in which CMI and PMS participate with and can show proof (current valid insurance card) of such coverage or have made other arrangements with CW and Practice Management Services.
I understand that CMI and PMS will bill NYS No-Fault Insurance on my behalf. I understand that CMI and PMS will bill Workers Compensation Insurance on my behalf. If I fail to prosecute this claim or it is denied or disallowed I agree to assume full financial responsibility.
I hereby authorize the release to CMI and PMS any medical, insurance, or other information needed for this service or related medical condition or claim. I hereby authorize the release of medical information to my insurance carrier and referring provider. I hereby authorize my insurance carrier to direct the payment of my medical benefits to Practice Management Services for the services provided to me by the professional staff of CMI. I am aware of CMI's Notice of Privacy Practices and that I have the right to request further information as needed. This authorization may be conveyed by original signature or photocopy, which shall be as valid as the original.
1. Notwithstanding that this bill may be submitted for insurance, patient and his/her legal/authorized representative(s) acknowledge responsibility for the balance shown on the patient statement for services rendered.
2. Patient agrees that, in the event, proceedings are instituted to collect monies due for services, that the patient waives all jurisdiction and venue requirements, and that venue and jurisdiction hall lie in Oneida County, in either Utica City Court or Supreme Court, or in Herkimer County in the Little Falls County Court or Supreme Court, and if the patient is found liable, also agree to be responsible for reasonable legal fees and costs related to such proceedings.
I authorize CMI and Practice Management Services to obtain and/or release films and medical information necessary for treatment, payment, and /or healthcare operation. This authorization shall remain in effect until revoked by the patient.