I, the responsible party, certify that the above information is true and correct to the best of my knowledge. I understand that I am financially responsible for all charges regardless of delays in insurance payment or denial of insurance coverage.
It is my responsibility to understand and have personally verified if my insurance is contracted with this practice and/or the doctor I am seeing.
I hereby authorize Soleil Surgical LLC to apply for benefits and receive payments directly on my behalf for covered services rendered. They may also disclose any or all parts of my clinical record to any insurance company covering services for the purpose of satisfying charges billed.
I further agree to pay all collection costs, attorney fees and any other collection costs that may be incurred in the attempt to collect outstanding patient responsibility amounts.
I also understand, that if any insurance payments are sent directly to me, it is my responsibility to send these monies directly to Soleil Surgical LLC immediately upon receipt.