Consent to Treat: I hereby authorize Drs. Hawks, Besler, Rogers & Stoppel (Drs. HBRS) to treat me/my child.
Requirements at time of service: I understand insurance cards must be presented at time of service or the patient will be self-pay until cards are presented or if insurance changes within treatment, cards must be presented before Drs. HBRS will file claims to new insurance. All CO payments, co-Insurance, deductibles, and non-covered services are due at the time of service. Not all services are a covered benefit. If your insurance company denies a service, the balance is due within 30 days. Verification of benefits is not a guarantee of payment. We do offer a discount on certain services if paid in full at the time of your appointment and if no insurance is filed.
Assignment of Insurance Benefits: I hereby authorize and assign, my insurance carrier(s), to make payment directly to Drs. HBRS of insurance benefits for services herein specified and otherwise payable to the insured. Drs. HBRS files both primary and secondary insurance as a courtesy to patients for the companies with which we participate. I understand and agree that I am financially responsible for Drs. HBRS for all charges incurred regardless of potential insurance benefits including but not limited to CO payments, deductibles, and non-covered services. I understand Drs. HBRS will not become involved in disputes between the patient and the insurance company. I understand it is my responsibility to verify with my insurance company the physician(s)treating me are covered under my insurance and to get referrals and/or authorization for services.
Minor Patients: Any patient under the age of 18 should be accompanied by a parent/guardian. I understand by signing HBRS' financial policy, I am solely responsible for any incurred charges for the below named patient. The parent who brings the child in for care is ultimately responsible for their bill and we will not get involved in support disputes.
Returned Check Fee: I understand that if Drs. HBRS receives a returned check, I will be charged $30 plus the amount on the check and I will be on a cash-only basis thereafter.
Non-Payment: We reserve the right to send an account to collection if not paid in full. If Drs. HBRS refers your account over to a collection agency you will be responsible for your balance plus the collection agency fee of 25%.