We are committed to providing the best patient care. As a service, we are happy to verify your out-of-network benefits and submit your out-of-network claims for you. We encourage you to contact your insurance carrier and become familiar with your benefits as well. Please remember that verification of benefits does not guarantee coverage. Please fill out the Insurance Verification Form below and allow 1-2 business days for verification. You will be notified via email.

ASSIGNMENT OF INSURANCE BENEFITS & VERIFICATION ACKNOWLEDGMENT

I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage or payment by my insurance company, and that I am financially responsible for all services rendered to me by ORA. I hereby understand, acknowledge and agree that ORA will bill any insurance provider I so designate on my the Insurance Verification form; however, if for any reason, such third party payor refused to pay all or part of the amount owed, I agree that I will be financially responsible for any unpaid amounts, including, but not limited to co-payments, co-insurance, deductibles and non-covered products or services. I also understand that all out-of-network (non-contracted) insurance billing services provided by ORA on my behalf are performed on a courtesy basis and can be discontinued by either myself or ORA, with written notice, at any time. I consent to the release of all protected health information by ORA and its agents for the purposes of healthcare management and/or for processing of medical claims and/or payment. I agree that I will notify ORA immediately of any changes in my insurance coverage or insurance provider(s). I acknowledge and agree that I have received a Notice of Privacy Practices.