Financial Information

The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services rendered. Prompt payment allows us to control costs. Outstanding accounts cost both of us time and money. Therefore, all patients will be required to establish financial arrangements for payment of their account.

I acknowledge full financial responsibility for all services provided, both those covered by insurance and also those non-covered services that may be deemed necessary for appropriate medical care. I accept full responsibility for knowing my insurance benefits and will advise the staff of Clark Holmes accordingly. As a courtesy to me, Clark Holmes will file all claims with my insurance company. If Clark Holmes does not have a signed contract with my insurance company, and my insurance company fails to pay my claim within 45 days, the account balance will be my responsibility. It is then my responsibility to contact my insurance company about processing my claim. I will be required to make payments on my account during this time. If my insurance company does pay, I will receive any necessary refund.

I understand that each month, I will receive a statement of services that is due and payable within 30 days of the statement date, unless Clark Holmes records indicate insurance is pending. If my payment is late, and if I have not made financial arrangements, Clark Holmes will mail a reminder notice indicating a problem with my account. If the account remains unpaid and is referred to a collection agency, all costs of collections, including reasonable attorney’s fees, will be my responsibility.

I hereby authorize Clark Holmes to communicate confidential information necessary to process my insurance claim to my insurance carrier by facsimile, electronic transmission, telephone, or mail. I authorize payment of medical and/or dental benefits to Clark Holmes for services provided.

I have read the above financial policy and agree to abide by the terms set forth in it.

 

_________________________________________ ______________________

PATIENT/LEGAL GUARDIAN SIGNATURE DATE

 

I authorize Clark Holmes to discuss my account with:

 

_________ All family members

 

_________ Only the following family members

 

Name _________________________ Relationship ____________

 

Name _________________________ Relationship ____________

 

_________________________________________ ______________________

PATIENT/LEGAL GUARDIAN SIGNATURE DATE


Clark Holmes firmly believes that a good doctor/patient relationship is based on understanding and open communication. Our staff has been instructed to make every effort to assist you in managing your account. We hope to avoid any disagreement over payment for professional services by clearly defining our policies at the onset. If you have any questions concerning this policy or need any assistance with your account in the future, please contact us immediately.

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