Assignment Of Benefits Financial Agreement - Prime Care Physicians printable pdf download

PRIME CARE PHYSICIANS, P.L.L.C.

PATIENT FINANCIAL POLICY

ASSIGNMENT OF BENEFITS - RELEASE OF INFORMATION FORM

THANK YOU FOR ALLOWING US THE PRIVILEGE OF CARING FOR YOU TODAY. WHETHER YOU ARE A

NEW OR ESTABLISHED PATIENT, WE WOULD LIKE TO INFORM YOU OF OUR FINANCIAL POLICIES FOR

THIS YEAR, AND YOUR FINANCIAL OBLIGATIONS FOR CHARGES INCURRED:

PATIENT NAME

DOB:

Acct#

▪IF YOU ARE COVERED BY ONE OF THE HEALTH INSURANCE CARIERS WITH WHICH WE PARTICIPATE,

WE WILL SUBMIT A CLAIM ON YOUR BEHALF – PROVIDED WE HAVE YOUR MOST ACCURATE

I request that payment of Medicare and/or __________________ insurance benefits be

DEMOGRAPHIC AND INSURANCE INFORMATION AND ELIGIBILITY OF BENEFITS AT THE TIME OF

made to Prime Care Physicians, P.L.L.C. on my behalf for any services furnished to me by

SERVICE. WE REQUIRE THAT YOU PROVIDE ALL CURRENT INSURANCE CARD(S), REFERRALS AND/OR

AUTHORIZATIONS TO OUR FRONT DESK UPON “CHECK-IN” FOR VERIFICATION OF NUMBERS AND

this provider: __________________________. I authorize the release of my medical

ELIGIBILITY, ALLOWING US TO CORRECTLY BILL FOR SERVICES. YOU ARE RESPONSIBLE FOR PAYMENT

information to Medicare or the Centers for Medicare and Medicaid Services and/or the

OF ALL CO-PAYS, CO-INSURANCE, DEDUCTIBLES AND/OR NON-COVERED SERVICES.

above carrier to determine the benefits payable for related services.

▪IT IS OUR POLICY TO COLLECT YOUR CO-PAY AND/OR PAYMENT FOR NON-COVERED SERVICES AT THE

Please also read and sign the section below if the above insurance is a non-participating

TIME OF SERVICE. WE ACCEPT CASH, CHECK OR CREDIT CARDS FOR YOUR CONVENIENCE. Fee for

carrier with Prime Care Physicians, P.L.L.C.

insufficient funds will be assigned a $25.00/per check charge. *** YOUR INSURANCE MAY ASSIGN

MORE THAN ONE CO-PAY FOR SERVICES RENDERED, SUCH AS PATHOLOGY OR EKG SERVICE. PLEASE

I understand that Prime Care Physicians, P.L.L.C. is NOT a participating provider with my

CHECK WITH YOUR PLAN’S COVERAGE PRIOR TO YOUR VISIT. *** IF YOU FAIL TO CANCEL AN

insurance company______________________ . I also understand that if a claim is

APPOINTMENT WITHIN 24-HOURS, YOU MAY BE ASSESSED A $75.00 OFFICE CHARGE.

submitted on my behalf to this insurance, I will still be fully responsible for any unpaid

▪IF YOU ARE COVERED BY A HEALTH INSURANCE PLAN OF WHICH WE DO NOT PARTICIPATE, ARE

balances.

CONSIDERING TO NOT PARTICIPATE WITH, AS A COURTESY, WE WILL BILL THESE SERVICES. BUT IF

YOUR CARRIER DECLINES PAYMENT OR SENDS YOU THE PAYMENT FOR SERVICES, YOU WILL RECEIVE

This assignment will remain in effect until revoked in writing by me, or my representative.

A BILLING STATEMENT FROM US AND YOU ARE RESPONSIBLE FOR PAYMENT WITHIN 30 DAYS.

Should my insurance coverage change, I understand that a new Assignment of Benefits

and Release of Information must be signed.

▪ AS A PARTICIPATING PROVIDER IN MEDICARE, YOU ARE REMINDED THAT YOU MUST MEET YOUR

ANNUAL DEDUCTIBLE OF $140.00 BEFORE MEDICARE WILL ACCEPT AND PAY FOR COVERED SERVICES.

__________________________________________________________________

YOU ARE STILL RESPONSIBLE FOR THE 20% CO-INSURANCE MEDICARE DOES NOT COVER. IF YOU

HAVE A SUPPLEMENTAL INSURANCE CARRIER, WE WILL BILL THEM AS A COURTESY ON YOUR BEHALF.

PATIENT SIGNATURE

DATE

IF THE SUPPLEMENTAL CARRIER DOES NOT COVER THE COST OF THE CO-INSURANCE, YOU WILL BE

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RESPONSIBLE FOR THE BALANCE DUE.

I have received the Notice of Privacy Practices from Prime Care Physicians, PLLC

▪FOR UNINSURED PATIENTS WE OFFER A PROMPT PAY DISCOUNT, PLEASE ASK REGISTRATION STAFF.

X__________________________________________________________________________________

▪BALANCES ARE DUE UPON RECEIPT OF STATEMENT. WE ACCEPT CASH/CHECK/MONEY

ORDER/CREDIT CARD (Master Card/Visa/Discover/American Express). PLEASE CALL OUR STAFF FOR

PATIENT SIGNATURE

DATE

QUESTIONS: 1-866-619-0111. *** PAYMENT ARRANGEMENTS CAN ALSO BE MADE AT THIS NUMBER.

WE WILL NOT BE SENDING RECEIPTS FOR CREDIT CARD PAYMENTS, YOUR STATEMENT WILL SUFFICE

REPRESENTATIVES TO WHOM MY MEDICAL INFORMATION MAY BE DISCLOSED:

FOR FLEX-SPENDING ACCOUNTS & EMPLOYER TRANSACTIONS. A COPY OF YOUR STATEMENT

BALANCE CAN BE PRINTED AT YOUR OFFICE VISIT.

________________________________________

_______________________________________

________________________________________

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PATIENT/RESPONSIBLE PARTY SIGNATURE

DATE

Assignment Of Benefits Financial Agreement - Prime Care Physicians

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