If patient is under the age of 18, Emergeny Contact should be a Paretnt or Guardian unless patient is an emanicipated minor.
Primary Insurance Information
Subscriber Information below (if differs from patient)
Secondary Insurance Information
I authorize Premier Surgical Associates and Foothills Weight Loss Surgeons to verify my insurance benefits on my behalf. I know that I am ultimately responsible for obtaining and understanding all of my insurance benefits.
Notice of Privacy Practices Acknowledged:
I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information. A copy is located on premiersurgical.com and foothillsweightloss.com under Patient Paperwork. A copy is also available at the office.
Premier Surgical Associates, PLLC PEASE READ
All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.
Financial Responsibility (to be signed prior to your visit):
I understand and commit to the following:
1. I have recieved a copy of Premier Surgical's financial policies and have read and understand these policies.
2. I will pay my cop-pay, deductible and co-insurance at the time of service.
3. I will provide the most current insurance information and immediately notify Premier Surgical of changes.
4. I surgery is required, all or a portion of my financial financial responsibility must be paid prior to surgery.
5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances.
6. I understand that I am responsible for all balances after insurance has paid.
7. If I have no insurance, I have informed Premier Surgical and I am responsible for 100% of all balances.
8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.
Insurance Authorization and Release:
I request that payment of authorized benefits - inclulding Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC, for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC, to act as my agent to help me obtain any required precertification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC, any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the orginal.
As of October 16, 2013, the FCC is requiring all businesses (including healthcare companies) to retrieve consent from their customers before enrolling their cell phone in auto-dialing. This includes appointment reminders, which obviously affects us.
By including your cell phone number, you have given Premier Surgical Associates, PLLC, consent to call your cell phone for appointment reminders using our automated system.
Missed Appointment Policy:
In order to provide the best care and service to our patients, we ask that you notify us 24 hours in advance to cancel and/or reschedule your office visit, ultrasound or other diagnostic test appointment. A minimum of 30 and up to 90 minutes is set aside for each appointment and your communication and compliance is much appreciated by your physician and supporting staff. Please be aware that if 24 hours notice is not recieved a fee of $25 may be charged to your account which must be settled before another appointment is scheduled. Please call us at 865.984.3413 if you are unable to keep your scheduled appointment. This will provide us an opportunity to reschedule your appointment to a more convenient time and avoid any additional charges on your account.
FOR MEDICARE SUPPLEMENT POLICIES ONLY
One Time Medigap Assignment and Release
I request that payment of the authorized Medigap benefits be made on my behalf to Premier Surgical Associates, PLLC, for services furnished to me by them. I authorize any holder of medical information about me to release it to:
Any information needed to determine these benefits to the benefits payable for related services. This will remain in effect until revoked in writing. A photocopy of this assignment and released is to be considered as valid as the original.
Please click SUBMIT to finish and send your form to our Foothills Weight Loss Surgeons office! Next, please complete the Patient History Form.