PLEASE CAREFULLY REVIEW AND SIGN AT THE BOTTOM OF THE PAGE TO ACCEPT.
Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a certain percentage of the charge. It is your sole responsibility to pay any deductible amount, co-insurance, or other balance not paid for by your insurance.
You are responsible for knowing if your insurance policy requires a referral to see the provider, or if there are special requirements for your insurance policy. To make your visit as easy as possible, we must have this information before you can be seen by the doctor. There may be certain routine services performed during your visit or upcoming visits that may or may not be covered. It is your responsibility to contact your insurance company prior to any procedure to see if they are covered.
I, the undersigned, consent to treatment necessary for my care. I hereby authorize release of any or all medical records to the referring physicians, my insurance carriers/Medicare/Medicaid and those involved in payment of my account. I understand that payment of charges incurred in the office is due at the time of service. I also understand that charges not covered by insurance remain my responsibility and assign insurance benefits to MiBella Gynecology, LLC. I agree to assume the financial responsibility for services not reimbursed under my insurance plan.
I, the undersigned, agree that if my account becomes past due, that my account will be turned over to a collections agency. All charges incurred to collect payment including collection agency fee, attorney fees and/or court costs, if such be necessary will be my responsibility and I hereby waive all rights to exemption under the Constitution of the State of Alabama.
Returned Checks: There is a fee of $30 that will be charged on your account for any checks that are returned by the bank. Any checks that are returned will void any previous payment arrangements and the account balance will be due in full immediately. You will be unable to write checks in the future.
Cash Services (Services that are not billed to insurance): PAYMENT/PRE-PAYMENT FOR ALL CASH SERVICES ARE NON-REFUNDABLE. In the event that you are unable to complete a pre-paid treatment program/regimen, you will be allowed up to one calendar year (from the date of your first missed appointment), to complete it as prescribed/recommended by Dr. Cowan. They may be transferred towards other cash services.
By executing this agreement, you are agreeing to pay for all services that are rendered. Your signature below indicates that you agree to all the terms and conditions contained herein.
I further agree that a photocopy of this original shall be valid as an original.