Fillable Eye Surgery Institute Signature On File, Assignment Of Benefits, Financial Agreement Form printable pdf download

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Eye Surgery Institute Signature on File, Assignment of Benefits,

Financial Agreement

Patient Name:__________________________________________________ DOB:___________________

Primary Insurance:

ID#:

Secondary Insurance:

ID#:

1. Medicare - I request that payment of authorized Medicare benefits be made on my behalf to ESI, for services furnished

me by ESI. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid

Services (formerly Health Care Financing Administration) and its agents any information needed to determine these

benefits or the benefits payable for related services. I understand my signature requests that payment be made and

authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the

HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the

insurer or agency shown. ESI accepts the charge determination of the Medicare carrier as the full charge, and I am

responsible only for the deductible, coinsurance and non covered services Coinsurance and deductible are based upon

the charge determination of the Medicare Carrier.

2. Medigap - I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form

or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency

shown. I request that payment of authorized secondary insurance benefits be made on my behalf to ESI, if possible or

otherwise to me.

3. Release of Information - ESI may disclose all or any part of my medical record and/or financial ledger, including

information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or

corporation (1) which is or may be liable or under contract to ESI for reimbursement for services rendered and (2) any

health care provider for continued patient care. ESI may also disclose on an anonymous basis any information

concerning my case, which is necessary or appropriate for the advancement of medical science, medical education,

medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of

this authorization may be used in place of the original.

4. Other Insurance - I understand that ESI may contract with other insurance providers.. The undersigned agrees that I

am individually obligated to pay the full charges of all services rendered to me by ESI if I belong to a plan that ESI does

not contract with.

5. Non-Covered Services - I understand that ESI's contracts with health care service plans (i.e., HMOs, PPOs) relate only

to items and services which are "covered" by the health care service plans. Accordingly, the undersigned accepts full

financial responsibility for all items or services, which are determined by the health care service plans not to be covered.

Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient's

contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient;

and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with ESI to

obtain necessary health care service plan authorizations.

6. Financial Agreement - I agree that in return for the services provided to the patient by ESI, I will pay my account at the

time service is rendered or will make financial arrangements satisfactory to ESI for payment. If an account is sent to an

attorney for collection, I agree to pay collection expenses and reasonable attorney's fees as established by the court and

not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the

legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the

patient, is hereby assigned to ESI. If co-payments and/or deductibles are designated by my insurance company or health

plan, I agree to pay them to ESI. However, it is understood that the undersigned and/or the patient are primarily

responsible for the payment of my bill.

Signature_______________________________________________________________ Date__________________

Eye Surgery Institute 813 SW Highland Avenue Redmond, OR 97756-3123

(541) 548-7170

Eye Surgery Institute Signature On File, Assignment Of Benefits, Financial Agreement Form

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