We appreciate you choosing our practice for your medical care. We strive to provide you with the best possible care available. We file insurance claims for our services with most insurance carriers. It is your responsibility to determine if Tuscaloosa Surgical Associates, P.C. (TSA) is in network with your insurance carrier. You are responsible for all allowable charges not covered by your insurance, including co-pays, co-insurance, deductibles, and non-covered charges. If you do not have insurance, we do provide a hardship financial plan that can be suited to your personal situation. You must complete this form, and make payments according to the payment schedule.
By signing below, I authorize Tuscaloosa Surgical Associates, P.C. to furnish information concerning my illness and treatment to my insurance company, and assign to the physicians all payments for medical services rendered to myself or minor dependents. I understand TSA may employ nurse practitioners or physician assistants and acknowledge I am responsible for all services rendered by the practice. I understand if my account is delinquent, it will be reviewed and may be placed with a collection agency. I understand this is a legal and lawful debt, and agree to pay all costs incurred in the collection of this debt. This includes any and all collection agency fees (33 1/3%), attorney fees and/or court costs, if necessary. I waive now and forever my right of exemption under the laws of the constitution and the State of Alabama and any other State.
I also agree, in order to service my account or collect monies I may owe, TSA and/or its agents may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which may result in charges to me. TSA and/or its agents may also contact me by text message or email, using any email address I have provided. Methods of contact may include the use of pre-recorded/artificial messages and/or automatic dialing systems.