You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.
1. I hereby authorize and give permission for Dr. Russell O. Schub, P.A., Advanced Endoscopy Center of Howard
County, LLC and Advanced Anesthesia, LLC to disclose my personal health information (PHI)* for insurance and
treatment purposes only. I am allowing Dr. Russell O. Schub, P.A., Advanced Endoscopy Center of Howard
County, LLC and Advanced Anesthesia, LLC to release all PHI (private health information) necessary for payment
and treatment of my specific health problem.
2. I hereby assign to you, my doctor, all medical and surgical benefits to which I am entitled, including Medicare,
private insurance and any other insurance.
3. I understand that I am financially responsible for all charges not paid by the said insurance company, including any
deductibles and co-pays, and that payments are due at the time services are rendered.
4. I understand and agree that in the event that I fail to make payment for services rendered to me, my name and
account may be turned over to an attorney or collection agency and I agree to pay collection agency’s fees for
collection, court costs, and/or reasonable attorney fees that may be incurred in the collection of an outstanding
balance.
5. This office reserves the right to charge a handling fee for any unpaid balance.
6. Verification of benefits is not a guarantee of payment or coverage. All charges are subject to medical review and
approval by my health plan. In the event, coverage terminates or services are not covered, I acknowledge that I
am responsible for all charges incurred based on contract provisions until its termination date.
7. The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this
healthcare facility. A copy of this signed, dated document shall be as effective as the original.
8. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT
OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.
I understand that I am financially responsible for all charges not paid by the said insurance company, including any
deductibles and co-pays, and that payments are due at the time services are rendered for office visits and 2 days
prior to all scheduled procedures at Advanced Endoscopy Center of Howard County, LLC.
Cancellation and No show Policy - Patients who cancel or reschedule an office visit or testing appointment with less than
24 hours notice will be assessed a fee of $50.00.
*For Monday appointments, cancellations/rescheduling must be done by 12 pm the preceding Friday.
Patients who cancel or reschedule a procedure with less than 72 hours (3 business days) notice will be assessed a fee of
$200.00.
*For Monday procedures, cancellations/rescheduling must be done by 12 pm the preceding Wednesday.
Patients who cancel or reschedule an infusion appointment with less than 72 hours (3 business days) notice will be
assessed a fee of $150.00.
*For Monday procedures, cancellations/rescheduling must be done by 12 pm the preceding Wednesday.