INSURANCE BILLING
I authorize Balance Counseling LLC (hereandafter called Medical Practice) to release any medical information to our billing company[Mid Michigan Medical Management] for paper & electronic billing of your insurance company. I authorize my insurance company to assign benefits to the Medical Practice. I understand that I am responsible for payment of services rendered by the Medical Practice regardless of reimbursement for these services by the insurance company and that any inaccuracy of information on this form may result in nonpayment by my insurance company. I agree to notify the Medical Practice immediately whenever I have changes in my health plan coverage.
ACCOUNT RESPONSIBILITY
I am responsible for payment to Medical Practice for all services rendered, due at the time of the visit. I also understand that if I suspend or terminate my care and treatment, any outstanding balance will be immediately due and payable. If I default on any payment obligations as called for in this agreement, the Medical Practice reserves the right to forward my information to collections, and an additional 30% may be assessed to my account to cover the costs of this action. There will be no obligation to provide continuing services to any client who names the Medical Practice as a creditor in any bankruptcy filing.
INFORMED CONSENT & NOTICE OF PRIVACY PRACTICES
I am consenting to treatment and have received and understand the contents of the Policies, including the Notice of Privacy Practices (HIPAA).