PATIENT FINANCIAL RESPONSIBILTY AGREEMENT AND ACKNOWLEDGEMENT OF RECIEPT OF PRIVACY PRACTICES
I understand I am required to pay all co-pays prior to being seen by the doctor unless arrangements have been made.
If my insurance requires referrals for the office visits, I take full responsibility to obtain them prior to my appointment. If this is not done, I agree to pay all claims denied because of lack of proper referral or I may choose not to be seen until a referral is received.
I understand that some items and/or procedures authorized by my insurance do not guarantee payment and may later be denied. I accept financial responsibility for these items and/or procedures if they are denied even if prior authorization is obtained. I also understand that these items cannot be returned.
I understand that some exams and/or procedures require services from an outside lab. I accept that these services may be billed independently by the facility to my insurance.
I understand that a $30.00 returned check fee will be charged for all returned checks.
I understand that a $25.00 fee may be charged for disability paperwork.
We require at least a 24 hour cancellation notice if for any reason you cannot make your appointment. I understand that a $25.00 fee may be charged for all missed appointments.
I understand that if I change my insurance, I am responsible to notify the office.
I understand I must give ALL insurance information at the time of my Initial Appointment.
I understand that there may be a charge for printing medical records.
I agree that my account will be “paid in full” upon receiving the statement. Any courtesy fees are only applicable upon full-payment of fees at the time of visit. If my account is not paid-in-full upon presentation of the statement, I agree to pay a monthly re-billing fee of $3.00 per month until paid.
I agree that in the event my account is turned over to an attorney or collections agency, I agree to pay any and all actual collection fees charged and or attorney’s fees, fees incurred in an amount not to exceed 50% of the balance due. I further agree that the jurisdiction for any action filed for the purpose of collection and any sums due on this account shall be the place where the contract was made, specifically Maricopa County, Arizona. A photocopy for facsimile of this agreement shall be considered as valid as the original.
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read) and understood the notice.
