FINANCIAL POLICY / PATIENT GUARANTOR AGREEMENT
1. On my behalf and on behalf of my spouse and minor children, including stepchildren, I hereby authorize treatment by Allergy Consultants, P.A..
2. I understand that payment of the required copay is due at the time of service, I direct and assign payment from any third party payor to Allergy Consultants. P.A. I understand that my insurance policy is a contract between me and the insurance company and that I am responsible to Allergy Consultants, P.A. for any charges not covered by my insurance. I also know that payment by the insurance company is not considered payment in full and that I am responsible for any amounts left unpaid by insurance for any reason.
3. Should your insurance company require a specialist referral from your primary care physician before you can seen by our physicians, it is your responsibility to obtain that referral prior to your appointment. Our contracts with the insurance companies prohibits us from seeing you without a referral and billing them for services. In the event that services are provided and your insurance is not in effect that day, or if your contract contains a pre-existing clause, remember that you are responsible for payment.
4. I hereby authorize the realease of any and all medical and/or charge information as is necessary for third-party reimbursement from Medicare, Blue Shield and/or any other agency involved in payment of my treatment or that of my family.
5. I understand that I will be charged the finance charge of equal to 1% per month on any balance billed and left unpaid more than 30 days. I further understand that any amount left unpaid for more than 30 days will be considered delinquent and may be referred to a collection agency or attorney as well as reported to the various credit reporting agencies.
6. If my account is referred to a collection agency and/or attorney for collection, I agree to be respnsible for the payment of an additional collection fee in the amount equal to 30% of my outstanding balance, inclusive of accrued interest. I also understand that there is a $ 15.00 returned check fee should a check be returned for any reason.
Signature of Patient/Responsible party
Date:___________________________________________________
Relationship to Patient:____________________________________________________________________________________
I hereby acknowledge that I have been presented with a copy of Allergy Consultants, P.A. notice of financial policy / guarantor agreement.
Signature:______________________________________________________________________________________________
Printed Name of Patient/Guarantor___________________________________________________________________________
Date:_________________________________________________________________________________________________