Practice Name: Pinnacle Internal Medicine Associates
Patient Name:
It is our office Policy to inform you of our patient payment procedure. Please review the section that is applicable to you.
Patient with Insurance: You are responsible for deductibles, co pays, non covered services, coinsurance and items considered “not medically necessary” by your insurance company. Please pay copayments as services are rendered. The remaining balance should be taken care of within one (1) month of notice from the insurance company. If you or your insurance carrier makes payment exceeding services your balance, reimbursement will be remitted. If payment cannot be made at each visit, payment arrangements must be made with the billing office prior to the visit.
Workers Compensation: As a Workers Compensation patient you may be covered by your employer if your injury is reported at work and verified with the employer. Be sure to inform the office personnel that your injury resulted during employment. The Patient is ultimately responsible for the balance.
Personal Injury: (accident). If you are a personal – injury patient, our office will bill the appropriate insurance carrier. If we are unable to obtain payment, the charges for the services rendered will be your responsibility. Please give all billing information needed. If an attorney is involved, please provide that information. The Patient is ultimately responsible for the balance.
Medicare Patient: Our office will submit your charges to Medicare and your secondary insurance carriers. You are responsible for deductibles, copays, and any “non covered services”.
Self Pay : (no insurance coverage) If you do not have insurance coverage, it is your responsibility to make payment for the services rendered at the time of the visit. If payment if full cannot be made, please contact our billing office to make Payment Arrangements prior to the service.
Assignment
___ I assign the benefits from my insurance carrier to this provider for services rendered to me.
___ I request that payment of authorized Medicare benefits be made to the above mentioned provider.
Release of Information
___ I authorize the Provider listed above to release to my insurance carrier andor CMS and its agents and/or my Medigap insurance any information needed to determine benefits.
Authorized Signature
I have read the above and agree to the Financial Policy, Assignment, and Release of Information paragraphs stated above that apply to me.
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Patient or Responsible Party Signature and Date
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Relationship to Patient if Patient did not sign above (print name)
