I agree to abide by the rules of Graves-Gilbert Clinic (the “Clinic”), including to the extent I am able, cooperation with physicians, mid-level providers (i.e., nurse practitioners, physician assistants) and Clinic personnel, and observance of the rights of other patients relative to the care and treatment of the above patient.
CONSENT FOR TREATMENT
I hereby authorize and consent to medical services including, but not limited to, diagnostic procedures, radiology procedures, laboratory procedures, local anesthesia, medical and/or surgical treatments when they are deemed necessary or advisable by any physician and/or mid-level provider employed by the Clinic and rendered to the patient shown above, under the general or special instructions of said physicians and/or mid-level providers.
ASSIGNMENT OF BENEFITS AND AGREEMENT FOR PAYMENT
I authorize direct payment to the Clinic of benefits provided under any health care plan or medical expenses policy due to me or payable on behalf of the above patient. I further authorize the Clinic to release any information required by any third-party payor regarding any claim for payment. I permit a copy of this authorization to be used in place of the original. Furthermore, I understand this document as well as my signature may be stored as an electronic image. I agree to pay for all medical expenses incurred relating to the treatment of the above patient. I acknowledge that all of the medical expenses not paid by my third-party payor(s) are my responsibility and I agree to pay for same upon demand.
Applicable to Medicare Patients: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or the Medicare Program or it’s intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I also, request payment of any government benefits payable on my behalf (or on behalf of the patient above) be paid either to myself or the Clinic under an assignment of benefits. The Clinic participates in the Medicare program. This means the Clinic accepts Medicare’s allowed amount for services covered by Medicare. Medicare will pay the Clinic for 80% of the allowed amount, less any deductible amount for which the patient is responsible. Patients with secondary insurance are responsible for ensuring that the Clinic has complete information on all insurance coverage.
STATEMENT OF FINANCIAL POLICY
The Clinic is a provider for many insurance plans and will be listed in your group’s provider list if we are participating in your plan. Ultimately, you are responsible for determining if the Clinic is a provider for your insurance plan. We will bill your insurance directly and receive payment directly from them. However, applicable copayments are expected to be paid at the time of service. Deductibles, coinsurance amounts and any services not covered by your insurance not paid at the time of service are due upon receipt of a Clinic statement indicating a patient due amount. If services are provided to you by a Clinic provider that is not a participating provider for your insurance plan, we will still bill your insurance. The filing of insurance claims is a courtesy ordinarily extended to Clinic patients. Our relationship is with you, the patient, not your insurance plan. All charges are your responsibility from the date the services are rendered. The Clinic will not enter into any dispute with an insurance carrier regarding a claim that is the responsibility and obligation of the patient.You are expected to bring your most current insurance card(s) each time you seek services at the Clinic. Failure to present your insurance card(s) at registration may result in you being considered a self-pay patient with the accompanying expectation of payment at the time of service. If you do not have insurance coverage, at least a partial payment will be expected at the time of service. If charges are not paid in full on the date of service, you will be requested to provide the Financial Counselor with credit or debit card information. This financial information will be utilized to pay for any services that remain unpaid for at least thirty days. The Clinic accepts Visa, MasterCard, and Discover credit cards.
The Clinic completes forms (i.e., disability), for a fee of $25.00 per form, paid in advance. The fee for completing forms is subject to change at any time without notice.
It is important that you keep your scheduled appointments. If you must cancel your appointment, you are expected to do so at least twenty-four (24) hours in advance so that another patient can be placed in that time slot. A missed appointment fee of $25.00 up to $50.00 may be charged for failure to keep appointments when adequate notice of cancellation has not been provided. The missed appointment fee is subject to change at any time without notice.
The Clinic charges a fee for all returned checks. The present fee is $25.00, subject to change at any time without notice.
All family members receiving services at the Clinic are billed under their own account. This is called individual billing. Statements will be mailed to the responsible party listed on the account with statements being mailed monthly on accounts with a patient due balance. Timely payment of the patient due balance is expected to avoid further statements and ultimately placement of the account with an outside collection agency. The responsibility for payment for services rendered to any dependent children where parents are divorced rests with the parent who seeks treatment. Any court ordered responsibility judgment must be determined between the individuals involved, exclusive of the Clinic.