Insurance Assignment and Self Pay Agreement
If you are uploading and providing updated or new insurance plan coverage, you agree to the folllowing terms:
I certify that I have insurance coverage with the primary insurance company, if applicable; and the secondary insurance payer, if applicable. I assign directly to "Cornerstone" Psychiatric Services, Inc. (including David Donahue, D.O., David Fawks, APRN, Nina Kirchgessner, APRN, Smitha Ajesh, APRN, Joan Flynn, LCSW and Nancy Stetter-Coblentz, LCSW or any staff of Cornerstone Psychiatric), all insurance payments, if any, otherwise payable to me for services rendered. I understand I am financially responsible for deductible, co-payments, co-insurance amounts, non-covered charges, and any and all balances not covered under a contractual agreement between "Cornerstone" and my insurance or other third party payer. I authorize the use of my signature for all insurance submissions. I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to "Cornerstone" for any services furnished to me by that provider.
If Self pay, I understand it is my responsibility to pay for services rendered at time of visit.
I understand and agree that "Cornerstone" may use my health care information to the insurance payer I am providing and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I understand that if an authorization is needed from my insurance plan, it is my responsiblity to obtain such authorizaton from my insurance plan and provide this to "Cornerstone".
All Document Uploads Agreement
I agree that the documents uploaded are being granted/released to Cornerstone Psychiatric Services, Inc. I give consent for Cornerstone Psychiatric Services and their Business Associates's to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I agree to not hold "Cornerstone" liable for anything related to uploading documents provided on this service.
By signing this form, you are consenting to the above assignment and agreements. I may revoke my consent in writing to Attn: Privacy Officer - Cornerstone Psychiatric Serivces, except to the extent that the practice has already made disclosures in reliance upon my prior consent.