Assignment of Benefits / Authorization / Notice of Collection Action
I understand I am responsible for knowing the benefits my insurance plan provides. In doing so, it is also my responsibility to verify proof of insurance by ensuring that the office staff has the most current/valid insurance card on file. I further understand that all co-payments are due at time of service and I am also responsible to pay other amounts due; these amounts may include annual deductibles, charges denied by my insurance company as not covered or not medically necessary, fees for in-office services and/or tests, and any fees incurred should my account require collection action. (E.G. late fees, collection agency, court or attorney costs).
Also please be advised our office may contact you via an automated system, or text messagge, regarding appointments and/or account status. I agree this authorization shall remain valid unless/until I rescind in writing.