- INDIVIDUAL’S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
- Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit.
- In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.
- If I am uninsured, I agree to pay for the medical services rendered to me at time of service.
- INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I hereby authorize and direct payment of my medical benefits to Bella Skin Institute on my behalf for any services furnished to me by the providers.
- AUTHORIZATION TO RELEASE RECORDS I hereby authorize Bella Skin Institute to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.
- MEDICARE REQUEST FOR PAYMENT I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in Bella Skin Institute I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
Insurance Responsibility Notice and Consent
It is not the responsibility of Bella Skin Institute to verify your insurance coverage or determine which services are or are not covered. It is ultimately your responsibility to understand your policy, its benefits, and the obligations it places on you. Therefore, if your insurance denies payment for any reason, the amount owed is your responsibility and must be paid within 14 days of insurance determination.
I have read and understand the above information and accept full responsibility if my insurance does not pay for services rendered.