Any monies payable to, Dr. Amanda S. Ayers, Dr. Steven H. Brown, Dr. Robert T. Lewis, Dr. Daniel J. Mullins, Dr. Andrew Raissis, Dr .Rachel Scott, Ly Tran PA-C, Robin Tedesco PA-C and/or Ann Navage APRN, will be paid directly to Colon and Rectal Surgeons of Greater Hartford, LLC.
I authorize the release of any medical information to my insurance carrier as requested by them. I understand that the specific type of information to be released includes my diagnosis, prognosis and treatment for physical illness, and, where applicable, mental health, alcohol or drug abuse, HIV test results, or AIDS or any AIDS-related diagnosis. I permit a copy of this authorization to be used in place of the original. This authorization will remain in force and effect until revoked by me in writing.
I authorize any medical benefits payable to me to be paid directly to Colon and Rectal Surgeons of Greater Hartford.
Medicare/Medicaid Patients - I authorize any holder of medical or other information about me to be released to the Social Security Administration and Health Care Financing Administration of its intermediaries or carriers, any information needed for this or related Medicare/Medicaid claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information Regulations pertaining to Medicare/Medicaid assignment of benefits also apply. I recognize and accept personal responsibility for immediate payment of charges not covered by my contract and agree to pay attorney's fees, court costs and a 15% collection fee if turned over to a collection agency, should I fail to make payment.
Commercial Insurance - I recognize and accept personal responsibility for immediate payment of charges not covered by my contract and agree to pay attorney's fees, court costs and a 15% collection fee if turned over to a collection agency should I fail to make payment. It is the responsibility of the patient to verify with their carrier benefit exclusions and limitations. In the event that Colon and Rectal Surgeons of Greater Hartford LLC does not participate with my insurance plan I accept personal responsibility for any amounts not allowed by my plan including any amounts beyond my plans "usual and/or customary" amounts.
I understand that if I do not provide accurate up to date insurance information that I may be held liable for any charges incurred.
In accordance with the offices' no show/cancellation policy should I need to cancel or reschedule an appointment I agree to call the office at least 24 hours prior to my scheduled appointment time. Should I fail to provide at least 24 hours' notice I acknowledge that there is a $25 fee that is not billable to my insurance that I will be responsible for paying prior to making another appointment.
By signing below I am in agreement with all statements listed above.