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Please remember that 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 percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance.
Please Initial: In order to control your cost of billings, we request that our charges for office visits be paid at the conclusion of each visit.*
Please Initial: If this account is assigned to an attorney for collection and/ or suit, the prevailing party shall be entitled to reasonable attorney’s fee and cost of collection.*
Please Initial: To the extent necessary to determine liability for payment and to obtain reimbursement, I authorized disclosure of portions of the patient’s record.*
I hereby assign all medical and/ or surgical benefits to include major medical benefits to which I am entitled including Medicare’s, private insurance, and other health plans to: Premier ENT, A Medical Corp. Johnny Arruda, M.D., F.A.C.S.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as a valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorized said assignee to release all information necessary to secure the payment. I hereby authorize evaluation and treatment by Johnny Arruda, M.D., F.A.C.S.
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