Patient Financial Responsibility Insurance Form Template

I acknowledge that i assume full financial responsibility for services rendered to me if my insurance carrier denies or does not cover my claim for these services.

Patient financial responsibility insurance form template. You are responsible for knowing your insurance policy. Patient guardian signature insurance carrier today s date this waiver will remain valid for one year from the original date of signature. Patient financial responsibility form self pay waiver thank you for choosing compass urgent care for your medical needs we are committed to providing you the highest quality healthcare. Patient financial responsibility authorization form thank you for choosing expedian care for your medical needs.

The purpose of this form is to help our patients understand about medical insurance eligibility coverage our office policy and medical services. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies. We are committed to providing you with the highest quality healthcare. Financial responsibility waiver form insurance authorization verification and co payments are the responsibility of.

Urological associates of southern arizona p c. Microsoft word nwea financial waiver for pts docx. As the patient guarantor it is your responsibility to know your insurance benefits and to provide our office with accurate and current insurance information. I understand that if my insurance company denies coverage and or payment for services provided to me i assume financial responsibility and will pay all such charges in full.

For example you will be responsible for any charges if any of the following apply. Individual s financial responsibility i understand that i am financially responsible for my health insurance deductible coinsurance or non covered service. Patient eligibility waiver financial responsibility form patient name. If my plan requires a referral i must obtain it prior to my visit.

It must be understood that we render our services on the basis that insurance companies may or may. If your specific insurance plan requires a referral it is your responsibility to obtain the referral from your primary care physician. Patient financial responsibility form 1. Notified by insurance and or provider.

Co payments are due at time of service. Blog about your care patient forms patient financial responsibility form patient financial responsibility form 07 10 2015 about your care patient forms. Co payments co insurance amounts or any other patient responsibility indicated by your insurance carrier or our financial policies which are not otherwise covered by supplemental insurance. A clear understanding of my financial responsibility.

We ask that you read make the appropriate selection and sign this form to acknowledge your understanding of our patient financial policies.