FINANCIAL POLICY

The following information is provided to avoid any misunderstanding concerning payment for professional services.

All professional services rendered are charged to the patient. When supplied with complete insurance information, we will file your insurance for you. The patient is responsible for all fees regardless of insurance coverage. It is customary to pay for services when rendered unless prior arrangements have been made with our business office. We are participating providers with Medicare, therefore, claims will be filed by Texas Regional Clinic and payment will be received at this office. A copy of this authorization and assignment shall be considered as valid as the original.

You understand that you are responsible for your account balance regardless of what any insurance pays. You hereby authorize Texas Regional Clinic to furnish information to my insurance carrier and/or attorneys concerning my treatments. You hereby assign to Texas Regional Clinic all payments for services rendered to myself and/or my dependents. • As a courtesy, we will file your primary and secondary insurance. We do not file third insurance.

• All charges for treatment become due and payable within thirty (30) days ofter your insurance payer has evaluated and processed your claim at which time you are responsible for any remaining balance.

• We will require payment of your co-pay and/or deductible & applicable co-insurance at the time services are rendered.

• The patient acknowledges that it is the patient’s responsibility to be aware of what services are covered and agrees to pay for any services deemed to be non-covered or not authorized by their plan{s).

• Medicare – We accept assignment. Please pay your 20% or allow us to file your supplemental policy. If you do not have a supplemental policy, we will ask you to pay the Medicare Deductible/Co-Insurance. Medicare and secondary carriers do not cover some procedures or supplies. Please make sure you understand which treatments and supplies are covered as you will be asked to sign a waiver stating that you understand when services ore deemed not covered and you will be responsible for associated charges.

• HMO’s -It is the patient’s responsibility to get referrals for visits. Patients seen without the requisite referral will be responsible for charges in full at the time of service.

• Self-Pay- If you do not currently hove insurance coverage, we ask that you coordinate payment prior to your visit. We do require payment in full at the time of service unless prior arrangements have been made.

• All Payers – it is the patient’s responsibility to verify that we are participating providers with your health plan. In the event that we do not participate with your pion, we will file your claim as a courtesy but you will be responsible for full payment for services rendered at the time of the visit.

• We may charge you a “No Show” fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date/time.

• Insufficient fees on returned checks will be $25.00.

ASSIGNMENT OF BENEFITS & NOTICE OF PRIVACY PRACTICES

I authorize Texas Regional Physicians to submit claims and receive payment for services which may be otherwise payable to me from all sources with whom I have contracted. I understand that I am financially responsible to Texas Regional Clinic for charges not covered or paid by this assignment and will adhere to the financial policies of Texas Regional Clinic in the collection of these charges.

I accept full responsibility for providing Texas Regional Clinic accurate and complete informationneeded for their assisting me in processing my claims for reimbursement of services. I authorize Texas Regional Physicians to release any information necessary to insurance carriers regarding illnesses and treatment necessary to process claims. I authorize the refund of overpaid insurance benefits where my coverage is subject to coordination of benefits.

CONSENT FOR TREATMENT

I hereby authorize and direct Texas Regional Clinic to administer or perform all treatments/therapies on the patient identified, including any additional services as they deem necessary or reasonable. I also hereby authorize the release of medical records to my insurance companies for the purpose of payment, treatment and healthcare operations. This authorization for consent to treatment is and shall remain valid until revoked. I have been offered or been given a copy of the Consent for Treatment and the Notice of Privacy Practices of. I have read or will read this policy. All my questions or concerns have been answered.