*** For existing pt: Thank you for filling-out this form. With the new healthcare guidelines, patient information's are sent to authorized patient-portal website and notified by email. ***
social security number
Able to leave messages.
9a. Person's Name, relationship to patient, phone#
**** 1) PATIENT WILL BE CHARGE A $30 NO-SHOW FEE. To avoid the NO-SHOW fee, we are asking you to call us before your appointment if you are not able to show-up. Thank you.
**** 1) You are ultimately responsible for knowing what your plan does and does not cover and the administrative rules. (i.e. in-network / out-network; out-of-pocket balance, copayment, coinsurance, deductible , Health-Saving-Account balance; Labs/Radiology/EKG; authorizations and referrals) **** 2) As a courtesy, we will verify your insurance eligibility and benefits. However, we cannot guarantee that the information received, is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement with.**** 3) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be "patient's responsibility" and/or "non-covered service", will be your responsibility. ie. any copays, coinsurance, deductible, and fees. **** 4) If you disagree with the "patient responsibility" amounts due to our office per your insurance's Explanation-of-Benefits(EOB), please immediately call your insurance company and our office for further explanation. **** 5) Failure to provide current insurance information to our office and/or reply back to insurance's request for additional information may result in the entire bill being your responsibility.
NOTE: Once you are done, click submit and you should see a green messages "... successfully submitted". *** A RED messages is an error. You need to correct and then click submit. THANK YOU