PATIENT REGISTRATION INFORMATION
Spouse’s or Responsible Party Information
Check Here If Same As Above
Assignment and Release
I, the undersigned, has insurance coverage with the above company and assigned directly to the Dr. I checked off at the beginning of this form all medial benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this digital signature on all my insurance submissions.
Responsible Party’s Digital Signature
HAYDEL MEDICAL CLINIC FINANCIAL POLICY
OUR PRACTICE POLICY
We are dedicated to providing you with the best possible care and service, and we want to help you understand our financial policies as an essential part of your care and treatment. To assist you, we have the following payment policy. If you have any questions, please feel free to discuss them with our staff. Unless either you or your health insurance carrier has made other arrangements in advance, full payment is due at the time of service. This includes all laboratory and x-ray services that might be performed. For your convenience we accept VISA and MasterCard.
If you do not currently have insurance coverage and you wish to pay for your doctor’s visit personally, full payment is required at the time of services. All outstanding balances are due at the time of your next check in. We do not bill for services rendered to “private pay” patients. Any problems with payments should be directed to our collection manager.
We have made prior arrangements with many insurers and other health plans. We will bill those plans with which we have an agreement and will collect any required co-payment at the time of service. The co-payments will be collected before you leave our office. If you have insurance coverage with a plan with which we do not have an agreement, we will prepare and send the claim for you, free of charge. In this case, your insurer will send the payment directly to you. Therefore charges for your care and treatment are due at the time of service. We will also bill your health plan for all services we provide in the hospital. Any balance due is your responsibility and is due no later than 30 days from receipt of a statement from our office.
I agree that if payment is not made in a timely manner and should this office find it necessary to place my account with an agency for collection. I also agree to pay any and all court costs and attorney fees, on any balance due and owing.
For all services rendered to patients under the age of 18 years old, the adult accompanying the patient is responsible for payment at the time of services.
In order to provide the best possible service and availability to all our patients, it is imperative that you call us for any cancellations at least one day in advance. As a courtesy to others, please contact us as early as possible if you know you will need to reschedule an appointment. Failure to cancel an appointment in a timely manner will result in a NO SHOW fee of $25.00. I have read and understand the financial policy of the Haydel Medical Clinic and I agree to abide by its terms. I also understand and agree that such policies may be changed from time-to-time by the practice.
Digital Signature of Responsible Party