Patient Information, Insurance, Authorization, Financial Policies Form
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1. IF MEDICARE IS YOUR PRIMARY INSURANCE AND YOU HAVE A SECONDARY INSURANCE, IT IS YOUR RESPONSIBILITY TO CONTACT MEDICARE TO NOTIFY THEM TO FORWARD YOUR MEDICAL CLAIM(S) TO YOUR SECONDARY INSURANCE.
2. YOU UNDERSTAND THAT YOU ARE FINANCIALLY RESPONSIBLE FOR ANY AND ALL SERVICES WE PROVIDE TO YOU. THIS WILL INCLUDE AHCCCS PROGRAM RECIPIENTS.
IF IN THE EVENT YOUR INSURANCE CARRIER DENIES PAYMENT FOR THE FOLLOWING REASONS: WE WILL SEEK PROMPT REIMBURSEMENT FROM YOU.
A. CAN NOT IDENTIFY MEMBER.
B. MEMBERS COVERAGE HAS TERMED/NOT COVERED UNDER THIS INSURANCE
C. BENEFITS MAXED
D. PENDED CLAIMS WAITING FOR MEMBER TO RESPOND TO COB/STUDENT STATUS.
* IF YOUR CARRIER DOES NOT RESPOND WITH PAYMENT WITHIN 45 DAYS, YOU WILL BE SENT A NOTICE FOR PAYMENT IN FULL.
3. YOU WILL BE CHARGED A LATE FEE OF $15.00 FOR STATEMENTS THAT GO UNPAID AFTER 30 DAYS PAST THE BILL DUE DATE. IF NO PAYMENT IS RECEIVED AFTER 60 DAYS OF THE BILL DUE DATE THE ACCOUNT WILL BE SENT TO COLLECTIONS AND YOU WILL BE DISCHARGED AS OUR PATIENT.
4. A $25.00 FEE WILL BE CHARGED TO ANY RETURNED CHECKS. YOU WILL BE OBLIGATED TO BRING CASH IN THE AMOUNT OF THE CHECK AND THE FEE TO OUR OFFICE WITHIN 72 HOURS AND WE WILL NO LONGER ACCEPT YOUR CHECKS.
5. AHCCCS –IF YOU ARE AN AHCCCS RECIPIENT SIGNING BELOW INDICATES YOU UNDERSTAND AND AGREE THAT YOU WILL BE CHARGED FOR AND WILL PAY ACCORDING TO THIS FINANCIAL AGREEMENT.
6. IF YOUR ACCOUNT IS SENT TO A COLLECTIONS FOR AN OVERDUE ACCOUNT YOU WILL BE RESPONSIBLE FOR ALL OF THE COSTS AND/OR BILLS INCURRED IN RELATION TO YOUR ACCOUNT.
WE WAIVE NO FEES. THE OFFICE OF THE INSPECTOR GENERAL CONSIDERS THAT UNLAWFUL. WE MUST MAKE A GOOD FAITH EFFORT TO COLLECT.
BY TYPING OR WRITING OR SIGNING YOUR NAME ON THE "SIGNATURE" LINE ON THIS FORM AND SUBMITTING IT VIA THE INTERNET, FAX, EMAIL, IN PERSON, ETC., TO SAN TAN FAMILY MEDICINE PC, YOU INDICATE THAT YOU HAVE READ AND UNDER STAND OUR FINANCIAL POLICIES, AND THEREFORE, YOU INDICATE AN AGREEMENT FOR COMPLIANCE TO OUR FINANCIAL POLICIES. AUTHORIZATION FOR TREATMENT, RELEASE OF MEDICAL INFORMATION, FINANCIAL POLICY AGREEMENT I authorize the health care providers at San Tan Family Medicine PC to perform procedures and treatment including the administration of medicine and local anesthetics along with other surgical and medical procedures that may be necessary. I authorize the release of medical information to specialty or other physicians who are participating in my health care. I authorize the release of any and all information necessary to process my insurance claim. I also authorize my insurance carrier to submit payment directly to the physician for services rendered. I understand that once my insurance carrier has made payment, if there is a portion left in my responsibility, I agree to pay the physician as agreed to with my contract between my insurance carrier and myself.
By typing or writing or signing your name on the “Digital Signature” line of this form and submitting it via the Internet, fax, email, in person, etc, to San Tan Family Medicine PC, you authorize San Tan Family Medicine PC to treat and release medical records as stipulated above, furthermore, you indicate that you have read and understand our financial policies and indicate an agreement for compliance to our financial policies.
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