Financial Agreement

FINANCIAL AGREEMENT/OFFICE POLICIES

CO-PAYMENTS AND BALANCES:

Co-payments are due at the time of check in, unless prior arrangements have been made with our Billing Department. This arrangement is part of your contract with your insurance company. If you cannot pay your co-payment, you may have to reschedule your surgery. Unpaid deductibles, co-insurance percentages, non-covered services and/or other outstanding balances are due upon check-in.

INSURANCE CANCELLED OR LAPSED OF COVERAGE:

If insurance cancels for any reason prior to or retroactive of date of surgery you will accept full responsibility for payment in full for commercial rate, benefits of the reduced contracted rate with insurance carriers will not be extended to you. Payment in full for services rendered is due within 30 days unless a written agreement with the business manager is agreed upon and signed. If payment is not made in full within 30 days, your account will be sent to collections.

ASSIGNMENT OF INSURANCE BENEFITS:

I hereby authorize release of information necessary to file a claim with my insurance company, and I assign benefits, otherwise payable to me, to the doctor or group indicated on the claim. I understand that I am financially responsible for any balance not covered by insurance. A copy of my signature is as valid as the original.

GUARANTEE OF ACCOUNT:

This is to certify that I, the undersigned, promise to be responsible for the payment of all charges for services rendered to the named patient. I further understand that all applicable charges are due at the time services are rendered excluding charges that my insurance company is contractually responsible for payment. If this account should require collection procedures, I the undersigned, will be responsible for any charges for services rendered. The undersigned will incur a financial obligation. Your signature below also represents authorization for treatment of the patient receiving services.

Note to Medicaid Patients: The Surgical Center of the Treasure Coast DOES NOT participate in the Medicaid program. If you are insured through the traditional Medicaid program or Medipass, the person who signs below will be responsible for all charges for services rendered. The undersigned will incur a financial obligation. Your signature below also represents authorization for treatment of the patients receiving services.

CANCELLED OR RETURNED CHECK’S/CREDIT CARD WOULD BECOME IMMEDIATELY DUE WITH ADDITIONAL $25.00 RETURN FEE. PAYMENT DUE IN CASH OR MONEY ORDER.