New Patient Enrollment
Dr. Tonya Cockrill | Dr. Emily Hung
Payment Of Benefits
I authorize the payment of benefits as determined by the insurance company directly to the physician. I understand that even though I have agreed to an assignment of benefits to the physician, I may still be responsible for any amounts not paid by the insurance company in the event that charges made are deemed not reasonable and customary and or not a covered benefit under my insurance plan. I also understand that it is my responsibility to notify the physician’s office in a timely manner of any insurance changes and to produce complete information including a new insurance card to file a claim within the guidelines of my insurance company to have the claim paid. I understand that the charges are my responsibility if I fail to inform the office of any change in coverage.
If you are a current HMO participant, you are required to bring a CURRENT REFERRAL form from your primary care physician and your membership card. If you do not have them in your possession at the time of your scheduled appointment, we will reschedule your appointment for you. During the course of your care here at The Woodlands Arthritis Clinic, it will be your responsibility to maintain a current referral. If you should come in for an appointment and do not have a current referral, you may either reschedule your appointment, pay for services rendered at the time of service, or call you insurance company and ask that a referral number be given to you or have them fax a referral to us.
If you are not a member of one of these plan, payment is requested at the time services are rendered. We will give you a receipt with the necessary information to submit to your insurance company for your reimbursement.
Electronic Claims Release Information
I understand this office sends all claims electronically. By signing this consent form, I give authorization to send all claims to the insurance company electronically.
Deductibles, Co‐Insurance, Co‐Pays and Self‐Pay account balances are due at the time services are rendered. If a balance remains on the account a statement will be issued to the address on file. It is your responsibility to inform us of any and all changes in address, phone numbers etc. Payment is due upon receipt. Any account that reaches a 90‐day status is in jeopardy of being turned over to a credit bureau for collections. Failure to pay will result in discharge from the practice. We will also report to your insurance company non‐compliance with your contract in regards to paying deductibles, Co‐Insurance, Co‐Pays etc. This office does not accept responsibility for collection of your insurance claim or for negotiating a settlement in a disputed claim. You are responsible for payment of your account within a 30‐day limit of our credit policy.
No Show and Same Day Cancelations
There is a $50.00 charge for all same day cancelations and no shows. More than two no shows may result in discharge from the practice.
There is a $50.00 charge for completion of forms including but not limited to FMLA Forms, Handicap Placard Forms, Disability Forms. Etc.
Returned Check Fee
There is a $50.00 charge for returned checks.
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