Responsible Party/parent/gaurdian(Skip if info is same as patient info)
INSURANCE INFORMATION
You are always responsible for your own medical bills. However, if another person?s negligence or carelessness caused your injury and you intend to recover the amount of your medical bills from that
person or his/her insurance company, please give us notice.
Is this a work related injury, auto accident or a claim that will be processed/paid by someone else or their insurance?
(If yes) Insurance Name, Claim number and Adjusters information
I understand that it is my responsibility to confirm with my insurance if a referral is in place (if needed) and that Dr. Jenq is in-network prior to being seen and that any increase in bill due to a lack of referral/out of network will be my responsibility.
Our financial policy is:
· We accept self pay for uninsured patients at time of service, payable with cash, check, Visa or MasterCard and Care Credit.
· MEDICARE. We accept assignment on Medicare claims. If you have Medicare, you will be required to pay your 20% coinsurance and your deductible at the time of service or show proof that you have met your deductible.
· If our physician is not in network with your insurance company, as a courtesy, we will file your claims for you, if you assign benefits to our physician. If your insurance company does not pay within a reasonable time, you will be responsible for payment.
· If our physician is in network with your insurance company, we will file your claim and you will be billed for deductibles, co-payments and co-insurance DUE AT THE TIME OF SERVICE.
· To avoid a late charge of $5.00 per billing cycle your payment must be received within 30 days of the statement date or 5 business days of the payment plan transaction date.
· A $30.00 fee will be assessed for any returned checks.
· Cancellations are required at least 24 hours prior to your appointment. There will be a $25.00 fee assessed for no show appointments. After 3 no show appointments you will be discharged from our practice.
· We offer payment plans for qualified accounts upon request.
· From time to time, as an executive decision, billing and costs may be waived to aid in the
treatment of patients. Nothing in this decision or act shall be construed as an admission of
negligence or substandard care but only an assistance to facilitate patient care.
Electronic Signature
