1. Payment. I understand that payment in full is due at the time of service except for those services which have been pre-authorized in advance or subject to insurance payment. We accept cash, American Express, Master Card, Discover and Visa and all debit cards with the Visa and Master Card logo. We do not accept personal checks.
2. Financial Policy re: Insurance. It is my responsibility to contact my insurance provider to inquire about my remaining yearly deductible balance and/ or coinsurance responsibility to avoid any unexpected costs. I understand that I will be financially responsible if services exceed the limits of my plan. I also understand that there may be certain procedures that may not be reimbursable under my insurance plan. This may be due to the procedure being considered cosmetic. Also, certain visits or procedures may require a referral for or pre-certification that I do not have at the time of a visit. Therefore, I understand that I am personally responsible for any fees or procedures not covered by my insurance plan by virtue of plan limitations or lack of referrals and pre-certifications or any other reason. I am also responsible for any co-pays, co-insurance or deductible payments. Your insurance company may refuse to approve your procedure in advance. In such case, you will not know if you procedure is covered by insurance until after the claim is submitted. Should your insurance company disapprove, after the procedure is done, it is your responsibility to pay all charges. I understand it is also my responsibility to notify my insurance plan of any hospital admissions. I understand that it is my responsibility to get any referrals from my primary care physician as needed. I will notify the doctor's office if I am no longer insured by my insurance plan and will be responsible for all bills from the date that my coverage ceases. I understand and agree that if for any reason my insurance carrier does not ultimately cover a procedure that was supposed to be covered, I am 100% responsible for the charges.
3. Medicare Patients. We are participating providers in the Medicare program. We will accept assignment on all pre-approved claims. Patients are responsible for meeting their annual deductible and paying for the 20% coinsurance. We will also file with secondary carriers if applicable. In the event that the secondary does not pay within 60 days, patients will be balance billed.
5. Authorization of Treatment. I hereby authorize Dr. Cameron Rokhsar to give me reasonable and proper care by today's standards. I further authorize and direct the above named clinical practice to release to governmental agencies, insurance carriers or others who are financially liable for my medical care all information requested to substantiate payment for medical services provided. I also permit representatives thereof to examine and make copies of all records relating to such treatment. I hereby assign and transfer over to the above named clinical practice sufficient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical care, to cover the costs of medical services rendered. I further acknowledge that once service is rendered, it cannot be canceled, refused, returned or refunded.
6. Governance Policy. A copy of the following information has been made available to me: Information regarding the ownership of the practice; expertise of the physicians associated with this practice, the Patient Rights and Responsibilities; HIPAA Policy and the Grievance policy of this organization.
7. Release of Information. I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to Cameron Rokhsar, MD.
I have read the above and agree to the terms. This agreement will remain in effect indefinitely.