I agree that when I receive any insurance payments for those services, I will:
1. Sign/Endorse the check, and I WILL NOT DEPOSIT or CASH it. (Unless otherwise instructed to do so by the office in the case of a bulk insurance check)
2.Under my signature, I will print the following:"Make Payable Only to Suffolk Vascular Associates"
3.I will enclose the check with the accompanying letters or forms, such as the Explanation of Benefits, in an envelope, and promptly send it to Suffolk Vascular Associates at the address on this letterhead. Or I will bring the check to the office within 5 business days from receipt.
I also understand that in the event that the check is not immediately sent to Suffolk Vascular Associates, I will be responsible to pay the full and entire fee for all services rendered, plus any additional collection fees and legal costs in connection with collecting this debt.
I will be provided a copy of this letter as a reminder as to what is required of me when I receive payment from my insurance company.
By signing below, you are stating you understand the conditions of receiving treatment at Suffolk Vascular Associates and will comply with all the terms above or will be liable for all bills.