New Patient Demographics : Dr Deshmukh and Dr Adeyemo

PATIENT/RESPONSIBLE PARTY FINANCIAL AGREEMENT THIS INFORMTION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CO-PAYS, DEDUCTIBLES, CO-INSURANCES, AND SERVICES RENDERED NOT COVERED BY MY INSURANCE. I WILL BE RESPONSIBLE FOR ANY NSF FEES AND MY BALANCE MAY DEFAULT TO COLLECTIONS IF NOT PAID WITHIN 90 DAYS OF RECEIPT OF STATEMENT. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO DR. GANESH DESHMUKH, MD. I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION WHEN NECESSARY. I HAVE READ THE FULL FINANCIAL POLICY AND AGREE TO THE TERMS. I HAVE BEEN GIVEN ADEQUATE ACCESS TO INFORMATION REGARDING HIPAA BY THIS OFFICE CONSENT FOR EXAMINATION: I understand that medical treatment may be necessary for the patient by Ganesh Deshmukh, M.D./or Adewunmi Adeyemo, M.D. or their associates or assistants. I understand the examination procedures will be explained to me and I shall consent to the partial or complete examination. I understand that the examination results will be provided to me with recommendations. The responsibility for any follow up examinations to check abnormalities found and treated, lies with me and not my physician, thereby release my examiner from all responsibility in connection with this examination. CONSENT FOR TREATMENT: I understand that medical treatment is necessary for the patient by Ganesh Deshmukh, M.D./or Adewunmi Adeyemo, M.D. or their associates or assistants. I hearby consent to and authorize the administration of all diagnostic and therapeutic treatment that may be considered advisable or necessary in the judgment of the physician. No guarantee or assurance has been given to anyone as to the results that may be obtained by such treatments.1. All co-payments are due at time or service. We accept cash, check, Visa, Mastercard and Care Credit.2. All balances must be paid prior to any surgeries being scheduled. This includes outpatient procedures including colonoscopy and EGD's and inpatient procedures.3. Our office will submit claims to your insurance company as a service to you. It is important that you know what your insurance plan covers. Services not covered by your insurance company are your responsibility.4. You doctor is here to manage your medical care. The Physicians are not experts on insurance and cannot be aware of all financial arrangements. Please discuss insurance problems and financial difficulties with the business office staff or the billing department. We will gladly work with you to make payment arrangements. Accounts over 90 days past due may be referred to a collection agency. I have read the above Acknowledgment and Agreements and fully understand the same.