Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is my responsibility to pay the deductible amount, co-insurance, or any other balance not paid by my insurance. Even though, as a courtesy, the office has sent an insurance claim, I understand that I will receive a statement of my account if there is an outstanding balance. I further understand the doctor cannot accept responsibility for collecting my insurance claim or negotiating a settlement on a disputed claim; and that I am responsible for the timely payment of my account and for all delinquency charges resulting from a failure to pay the account promptly. If this account is assigned to an attorney for collection/and or suit,the prevailing party shall be entitled to reasonable attorney fees and costs of collection.
I understand that the office will collect my payment at time of service based on the benefits quoted to them by my insurance company. I further understand that a quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.
I understand that it is my responsibility to notify the office in a timely fashion of any change in my insurance coverage or status. I understand that the office retains the right to charge the full fee at time of service if my new insurance has not been verified by the office.
In order to control costs, it is required that payment be made at the time of service unless other arrangements have been made with our office.