Common use of Insurance/Authorization Clause in Contracts

Insurance/Authorization. Assignment of Insurance Benefits: I hereby authorize payment of medical benefits directly to ▇▇▇▇ Pediatrics. I further authorize the release of any medical information necessary for processing the insurance claim and any referral necessary for the care of the patient. I permit a copy of this authorization to be as valid as the original. I understand that all costs not paid by the insurance will become my responsibility unless otherwise prohibited by state or federal regulations. I understand that if I do not inform ▇▇▇▇ Pediatrics of changes in my insurance coverage within 30 days from the date of service that I may be responsible for any charges incurred due to a delay in timely submission of charges. If the patient is covered by Medicare/Medicaid, I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical information about the minor child named herein above to release to the Social Security Administration, it’s agencies, intermediaries, or carriers, any information needed for this or a related Medicare claim. I request that the payment of authorized benefits be made on the patient’s behalf I assign the benefit payable for physician services to ▇▇▇▇ Pediatrics or the organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I also authorize ▇▇▇▇ Pediatrics or the organization to appeal any denial of benefits on the patient’s behalf. Insurance Claims/Payment: As a courtesy, ▇▇▇▇ Pediatrics will file your insurance claims for you; however, in the event that your insurance company denies payment for any reason or has not paid within 45 days, the parent(s) and/or guarantor will be responsible for any balance due. It is also the parent(s) and/or guarantor’s responsibility to provide current insurance information, including the insurance subscriber number and mailing address, and to follow up on any benefit questions with the insurance carrier. You are responsible for informing ▇▇▇▇ Pediatrics of changes in insurance coverage within 30 days from the date of service, you may be responsible for any charges incurred due to delay in timely submission of charges. We must emphasize that we are a medical care provider; our relationship is with the patient and not the insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. Patient Account Charges and Statements: Co-­‐Payment and/or any balance due on your account are requested at the time of your scheduled visit; we accept cash, check, and credit card. If you have no insurance plan at the time of your visit you will be required to pay 100% of the visit charges before being seen by our practice. You may contact our billing personnel to arrange and sign a monthly payment plan agreement if necessary. ▇▇▇▇ Pediatrics may impose a collection fee and interest charge of 1.5% per month on any unpaid balance. In addition, a billing charge of $5.00 may be charged for each statement a patient receives after the initial one.