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*4 New Patients: Patient Financial Responsibility

Patient Financial Responsibility

Please provide the receptionist with your current and active insurance information prior to your appointments, i.e. insurance card. Contact your insurance company and be familiar with your plan, i.e:

Co-pays are mandated by the insurance company as written in your plan. They are collected at the time services are rendered and can not be waived for any reason. Our contracts with your insurance will not allow us to do this.

If your insurance requires assignment to a Primary care provider (PCP), please call the insurance company prior to your visit and assign Dr Choi as your PCP.

If you?re being seen for an office visit and motor vehicle accidents, it is your responsibility at check-in to inform the receptionist which type of visit you will have, i.e. medical or motor vehicle. These visits can not occur on the same day, per the insurance.

If your insurance is set to change or term, you must notify the office before the next appointment.

I acknowledge that Dr Choi is in network with my insurance company, but if he is not, i.e out-of-network, I accept full responsibility of billing charges.

I have read and understand the patient responsibilities regarding my medical insurance as presented by HOME TOWNE FAMILY MEDICINE. By signing this form, I will provide active insurance information and assign Dr Choi as my PCP. I am responsible for any remaining balances after insurance processes the claims. This includes; in network provider charges, deductibles, co-payments, co insurance, out of network provider charges, and non-covered services rendered at HOME TOWNE FAMILY MEDICINE.

By entering your name above in text, you are acknowledging this as your electronic signature.
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