Naples Vascular Specialists

FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS IMPORTANT-PLEASE READ I have read and understand the Financial Policy of Naples Vascular Specialists LLC. I agree to be bound by these terms. I also understand and agree that such terms may be amended by Naples Vascular Specialists LLC at any time. ASSIGNMENT OF BENEFITS FINANCIAL RESPONSIBILITY ALL services rendered by Naples Vascular Specialists LLC and its providers are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our Business Office. Necessary forms will be completed to file for insurance carrier payments. I understand that I am responsible for turning over any payments and Explanation of Benefits from my insurance carrier that I receive directly for any services provided by Naples Vascular Specialists LLC and its providers within seven days of receipt or be subject to finance charges and the cost of the collection process. ASSIGNMENT OF BENEFITS I hereby assign all service benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Naples Vascular Specialists LLC for all services rendered to myself and/or dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. Furthermore, I understand that I am waiving any anti-assignment clauses that are written in to my health care contract. I have requested that Naples Vascular Specialists LLC be my agent in the filing, processing and appealing of claims related specifically to all services rendered by their Practice. I understand that I have the opportunity to submit my bills directly to my health insurance carrier but have chosen voluntarily to have the claims submitted by and paid directly to Naples Vascular Specialists LLC with accompanying Explanation of Benefits. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Naples Vascular Specialists LLC to (1) release any information necessary to insurance carriers relating to illness and treatments (2) process insurance claims generated in the course of examination or treatment and (3) allow a photocopy of my signature to be used to process insurance claims for the period of ?lifetime? this order will remain in effect until revoked by me in writing. I have requested services from Naples Vascular Specialists LLC on my behalf and/or my dependents and understand that by making this request I become fully financially responsible for any and all charges incurred during the course of the treatment. I further understand that fees are due and payable on the date that all services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this Assignment of Benefits is to be considered as valid as the original.

Patient First and Last Name * Date Agreed to Terms * Patient Signature to Agree to Terms *