Release and Assignment Patient Financial Responsibility

Patient is responsible for knowing their own insurance policy. If you are not familiar with your plan, please contact your carrier for information.

Patients are required to follow all registration procedures including:

• Verifying and updating personal information
• Updating any changes in insurance carriers

A copy of your insurance must be on file for insurance to be billed. If we do not have a card on file, or are unable to verify your eligibility for benefits, you will be treated as a self-pay patient.

Patients are responsible for all payments, copays, coinsurance deductibles and all other procedures and treatments not covered by their insurance.

If partial payments are made by your insurance company, patients are responsible for the remaining balance.

To my Insurance Carrier(s):

1. I authorize the release of any medical information necessary to process my insurance claims.
2. I authorize and request payment of medical benefits directly to this provider.
3. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me.
4. I agree that a photocopy of this form may be used in lieu of the original.