As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement
from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
All services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless patient has insurance coverage in which Paducah Physiatric Partners is a participating provider.
Patients who carry insurance understand that all services furnished are charged directly to the patient and that he or she is personally responsible for payment of all services.
This office will prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.
However, this office cannot render services on the assumption that our charges will be paid by an insurance company.
I authorize the practice to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such care to third party payors and/or other health practitioners.
I authorize and hereby request that my insurance company pay directly to the practice.
I authorize Paducah Physiatric Partners, P.S.C. to represent me in any dispute with my health insurance company, including complaints, reviews, appeals and/or arbitration.
I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content. *Authorize
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