Ali Medical, LLC - Publicforms

Available Forms

Payment Plan Authorization Form - Ali Medical, LLC REQUIRED-Consent to Obtain Medical Information from Other Providers / Entities REQUIRED-COVID19 Screening Form-ONLY For INPERSON Office Visits REQUIRED-Financial Responsibility Form REQUIRED-HIPAA Form - Sharing Health Information REQUIRED-New Patient Demographics Patient Medical History - Dr. Shereen - Rheumatology

REQUIRED-Financial Responsibility Form

First Name *

Type your First Name

Last Name *

Type your Last Name

Date Of Birth *

Your Date Of Birth

PATIENT STATEMENT OF FINANCIAL RESPONSIBILITY

Please read and Check each statement below

I authorize Ali Medical to release information regarding my medical history and treatments to my insurance company in order for them to be paid.

I authorize payments for my services to be paid directly to Ali Medical from my insurance company.

I will provide Ali Medical with my current insurance information and any referral I may need.

I understand that if I do NOT provide current insurance information or a current referral I will be responsible for that day, any days forward, and any procedures performed until I provide the current information. The information must be provided within 30 days so that my claim(s) can be processed by my insurance company. Failure to provide said information will result in all fees being the full responsibility of myself/legal guardian.

I understand that any copays, self pay amounts, or past due amounts are due at the time of service, and if I do not have payment at the time of service I am aware that I may be asked to reschedule.

I understand that the staff and doctor of Ali Medical are not aware of my personal insurance company?s plan information, including: referrals, deductibles, coinsurance, and/or copayments for my plan. It is my responsibility to find out that information.

I understand that at any time during or before my treatment I can ask for and receive information on the cost(s) of any treatment that is being performed or will be performed on me.

I understand there is a fee for copies of my medical records or any paperwork needed for completing disability requests.

Signature

Signature *

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Date this Form is Signed

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