Billing
As a courtesy, Dr. David H. Fisher Jr. and staff will attempt to verify your insurance coverage and verify you upon check-in of your any required co-payment, deductible, or payment at the time of visit. However it is ultimately your responsibility to know your insurance policy and provide the office with accurate insurance information. Delay of providing proof of active insurance coverage will result in full payment due immediately.
Authorization of Benefits and Release of Information
I hereby assign all medical and/or surgical benefits to which I am entitled, inculing Medicare, private isurance and any other health plan to Dr. David H. Fisher Jr. & Assoc. This assignment will remain in effect until revoked by me in writing.A photocopy of this assignment is to be considered as valid as original. I understand that I am financially responsible for all charges whether or not paid/covered by said insurance and payment due at the time of visit. I hereby authorize said assignee to release all information necessary to secure payment. I understand there is a 35.00 for all NFS checks.
Payments
Payment is expected from you and your insurance carrier within 45 days of claims submission date. Statements are not sent to you until your insurance carrier(s) has completed your processing claim(s). Should your insurance carrier delay processing of your claim due to negligence or falsified information, you will be billed for services rendered and no other claims will be filed. All accounts over 90 days past due of final judgment of said insurance company will be sent to collections and you and your family members may be discharged from our practice.
Consent To Treatment
I hereby voluntarily and knowingly consent to and authorize my physician or other health care professional, or his/her designee, professional staff and it's employees, either individually or collectively to carry out, or caused to be carried out, diagnostic testing, examination, refraction and/or medical treatment, including any and all procedures which my physician or his/her designee. In their best judgement may deem proper for my healthcare. I acknowledge that I hereby grant permission for Dr. David H. Fisher Jr. and staff to view external prescription history and/or external healtn information documents and incorporate these into my medical record.
Authorization for Release of Information
For purpose of expediting payment of my account and processing of benefit claims resulting for my visit and for the assessment of damage claims or potential claims against Dr. David H. Fisher Jr. & Assoc. and staff and insures, I hereby expressly wiaver my rights and privilege under Louisiana Revised Statue 13:3734(said statue) and authorize the release of insurance information directly to my insurer(s), worker's compensation carrier or other legal medical compensation benefit provider(s) as well as to insurer(s) Dr. David H. Fisher Jr. & Assoc. and staff, or the legal representatives of any of them as well as to any collection agency or attorney if my account is not paid within said time. This authorization include all medical, administrative and financial records, information of transactions, including all perosnal and insurance data, photographs, drawings or other graphic representations contained therein, as well as the "communication" of such information as defined by said Statue, reagardless of whether such payment information is in oral written or printed from or mechanically stored on tape, audio or visual media. I further authorize, and agree to be bound by, the use of carbon or photo static reproductions of this agreement.
I certify that i have read the foregoing legal instrument and that I understand each of the provisions contained therein. I agree that the terms of this agreement or legally binding upon me until the end of this calender year and cover all appointments/procedures within this calender year unless I expressivley revoke and or all of them in writing directed to and received by Dr. David H. Fisher Jr. & Associates.