Your insurer may reimburse you directly for the services rendered.
By signing this document, you promise to promptly pay any amount due and agree that you are fully responsible for any services rendered by Dr. Ronald D. Blatt, his associates and/or The Manhattan Center for Gynecology.
I am aware that I may receive payment directly from my insurance company. Should this occur, I will immediately forward any checks received to the practice. In order to properly credit your account, please send the check and the explanation of benefits received to the address provided at the bottom of this form. Please note on your envelope Attention Collections Department. If you have questions please call us at 212-813-2146.
Should I fail to make payment, I understand that I am subject to legal action. I will be responsible for any fees (legal or other) incurred by Dr. Ronald D. Blatt MD or The Manhattan Center for Gynecology to recover any balance owed. The amount to be collected would be my current account balance plus a collections fee of 40% added to this balance.