1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Amar Atwal, MD, PC d/b/a Atwal Eye Care, for services furnished to me by Amar Atwal, MD, PC d/b/a Atwal Eye Care. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid
Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or
elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Amar Atwal, MD, PC d/b/a Atwal Eye Care accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.
2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information
to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Amar Atwal, MD, PC d/b/a Atwal Eye Care, if possible or otherwise to me.
3. RELEASE OF INFORMATION: Amar Atwal, MD, PC d/b/a Atwal Eye Care may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under
contract to Amar Atwal, MD, PC d/b/a Atwal Eye Care for reimbursement for services rendered, and (2) any health care provider for continued patient care. Amar Atwal, MD, PC d/b/a Atwal Eye Care may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authorization may be used in place of the
original.
4. OTHER INSURANCE: I understand that Amar Atwal, MD, PC d/b/a Atwal Eye Care maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office and that Amar Atwal, MD, PC d/b/a Atwal Eye Care has no contract, express or implied, with any plan that does not
appear on the list. The undersigned agrees that I am individually obligated to pay the full charges of all services rendered to me by Amar Atwal, MD, PC d/b/a Atwal Eye Care if I belong to a plan that does not appear on the above mentioned list.
5. NON-COVERED SERVICES: I understand that Amar Atwal, MD, PC d/b/a Atwal Eye Care contracts with health care service plans (i.e., HMOs, PPOs) relate only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services,
which are determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient; and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Amar Atwal, MD, PC d/b/a Atwal Eye Care to obtain necessary health care service plan authorizations.
6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Amar Atwal, MD, PC d/b/a Atwal Eye Care, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Amar Atwal, MD, PC d/b/a Atwal Eye Care for payment. I understand and agree
that if my account is turned over to a collection agency for non-payment, I will incur an added fee of up to $50 to cover the collection company’s fee. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby
assigned to Amar Atwal, MD, PC d/b/a Atwal Eye Care. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Amar Atwal, MD, PC d/b/a Atwal Eye Care. If I have a high deductible insurance plan, I understand that I am required to pay a $50 deposit at the time of service for each appointment and I will be billed for the remaining balance.
7. CANCELLED, RESCHEDULED, NO SHOW APPOINTMENTS: I understand that I must notify Amar Atwal, MD, PC d/b/a Atwal Eye Care at least 24 hours in advance of an appointment if I need to cancel or reschedule or it will be considered a NO SHOW. If I do not cancel or reschedule within 24 hours or if I fail to show
up for my scheduled appointment, I will be billed a $25 fee. A second NO SHOW appointment will be billed at $50 and a third NO SHOW appointment will be billed at $75. A third NO SHOW will be reviewed for possible release from the Practice. If I arrive more than 15 minutes late for my appointment, I understand it may be considered a NO SHOW and I may have to reschedule my appointment and incur a NO SHOW fee as stated above.