Medical Insurance Attestation

Medical Insurance Attestation

Please find the new patient paperwork attached for your upcoming appointment. Please have all pages filled out and signed upon arriving at our office. Also bring your identification and insurance card(s) and arrive a few minutes before your appointment time. If you do not have your paperwork completed, please arrive 20 minutes earlier to allow ample time.
Do you have any health insurance coverage?*

NoYes
Are you able to upload a FRONT and BACK copy of your Driver's License?

YesNo
Please upload a FRONT copy of your Driver’s license or pictured ID.

Cancelof
Please upload a BACK copy of your Driver’s license or pictured ID.

Cancelof
Full Name*
Signature*

Clear
Date*

MonthDayYear
Date
Are you able to upload a FRONT and BACK copy of your Insurance Card?

YesNo
Please upload a FRONT copy of your Insurance card.

Cancelof
Please upload a BACK copy of your Insurance card.

Cancelof
Please upload a FRONT copy of your Driver's License.

Cancelof
Please upload a BACK copy of your Driver's License.

Cancelof
If you are unable to upload your insurance card, please provide the following information:
Primary Insurance Carrier:
Subscriber's Name:

First NameLast Name
Policy Number:
Group Number:
Provider Phone Line (usually listed on the back of card):
PATIENT FINANCIAL POLICY

Rosenthal Consulting Solutions, LLC

331 Milam Street, Suite 200

Shreveport, Louisiana 71101

Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our office staff.

Rosenthal Consulting Solutions, LLC may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you. If your insurance company does not provide payment within 60 dates of initial submission you will be responsible of any balance due.

• Unless other arrangements have been made in advance by you, your employer, or your health insurance carrier, payment for treatment and services are due at the time service is provided. We will accept HSA cards and all major check cards.

• If you have insurance plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due and the time of service. We accept HSA, money order, and all major credit and debit cards. We do not accept CASH or CHECK.

• You must inform this office of all insurance changes and authorization/referral requirements. In the event this office is not informed you will be responsible, or any charges denied.

• Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due.

• Appointment cancellations require a minimum 24-hour notice. If less than 24 hour notice is provided, there will be a $75.00 charge. Your insurance company does not cover this fee.
Full Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: