I, First Name* Last Name*, have been advised that Drs. Myers, Srivastava, Nuriddin, Fernandez, Mallick and/or Surgery South, P.C., may not be an "in-network provider" with my insurance plan Insurance Name*; therefore, services provided to me and billed by Surgery South P.C., may be considered "out-of-network"services. Under this acknowledgement, I understand that my insurance carrier may pay for services rendered at a lower rate or not at all, compared to those considered as "in-network." I agree to pay 100% of the total charges billed on my behalf should the insurance company deny payment of services. I will assume responsibility to respond to any financial correspondence furnished by Surgery South, P.C., and I also agree to pay any outstanding/remaining difference(s), if my initial out-of-pocket payment is not sufficient to satisfy my account once my insurance company has been billed. We advise patients to verify "in-network" status with their insurance carrier using Tax ID# 58-1375107.
If representative, please give full name and state relationship
* Any overpayments or deposits on accounts will be appropriately refunded once the account has been adjusted and insurance has paid all of the claims in full. SurgerySouth does not provide separate refunds including surgery deposits.