Louisville Lifestyle Medicine (LLM) appreciates the confidence you have shown in choosing us to provide for your medical needs. The service you have elected to participate in implies a financial responsibility on your part. This responsibility
obligates you to ensure payment in full of your fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for the payment of your bill.
You are responsible for payment of any co-payment at the time of service and for any deductible /coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your
coverage. You are responsible for any amount not covered by your insurer. lfyour insurance carrier denies any part of your claim, or if you and your provider elect to continue treatment past your approved period, you will be responsible for your
account balance in full. If your account is not paid in full and is referred to a collection agency, any fees incurred in collecting on your unpaid balance will be your responsibility. For your convenience, we accept cash, checks and most major credit cards. Payment is expected by payment due date on your Monthly Patient Statement. Payments can be made at LLM, mailed to the address on your statement, or by calling our office at 502-365-4545.
I have read the above policy regarding my financial responsibility to LLM for providing medical services to the above named patient or myself. I certify that the information provided is, to the best ofmy knowledge, true and accurate. I authorize my insurer to pay any benefits directly to LLM. I agree to pay LLM the full and entire amount of all bills incurred by me or the above-named patient, if applicable, any amount due after payment has been made by my insurance carrier.