In consideration of the treatment provided at GDHC to me or my child or dependent, I agree to pay GDHC for such treatment. If private health insurance, Medicare, Medicaid, other governmental or other insurance programs cover the treatment, I authorize GDHC to bill any such insurer for all charges incurred in connection with the diagnosis, care and treatment. My insurance coverage may provide that some amount of the bill will remain my personal responsibility, such as my deductible, co-payment, co insurance or charges not covered by my health insurance, Medicare, Medicaid or any other programs for which I am eligible. I understand that certain payments may be required at the time of, or in advance of, services being provided. I also understand I will be billed for any charges not paid by my insurer, and I will be responsible for paying them. I understand and acknowledge that:
- my health insurance, in any form, not be billed for that service or be notified that the service was provided.
- rendered, and if I do not pre-certify for such services, my benefits may be reduced or lost, but I will still be responsible for paying GDHC for the services. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan and my certificate of coverage.
- have identified, I will be responsible to pay all list charges for the treatment and services received.
I hereby assign to GDHC and the professionals involved in my care, all my rights and claims for reimbursement under any private health insurance policy, Medicare, Medicaid or any other programs that I identify for which benefits may be available to pay for the services provided to me, and authorize payment for such services to be made directly to GDHC.