Release of Information: I authorize the providers and staff of Reliant FAS PLLC to: Release to any third party payor such as an insurance company or governmental agency any medical information contained in my records when such material is required in connection with determining a claim for payment. Release of any medical information accumulated in the course of my examination or treatment to any other requesting doctor, hospital or nursing home. I authorize the release of any medical information to the providers at Reliant FAS PLLC that might be contained within any other doctor or hospital records; including x-rays, laboratory reports, or other information
Financial/Payment Guidelines: Payment is due at the time of services. This includes all co pays, deductibles, and co-insurance. If your insurance company requires a referral, it is in the patient’s responsibility to obtain the referral prior to your appointment. I authorize payment to Reliant FAS PLLC and the Providers on staff at Reliant FAS PLLC of any group and/or individual surgical and/or medical benefits otherwise payable to . I authorize the payment as a direct assignment of my rights and benefits under my insurance policy. If my policy prohibits direct payment t Reliant FAS PLLC, I hear-by instruct and direct my insurers to make the check payable to me and mail the check to: Reliant FAS PLLC -1650 W. Rosedale ST. Suite 204, Fort Worth, TX 76104. I authorize that my insurance benefits payable to Reliant FAS PLLC will be paid by my insurers in a reasonable and timely fashion. I assign my right to Reliant FAS PLLC to file a complaint with the State of Insurance Commissioner or with any state or federal regulatory agency that covers my insurers if payment is not made to Reliant FAS PLLC within a reasonable time period.
Authorization of Care: I authorize the providers Reliant FAS PLLC to examine me and to make such tests and perform such procedures as they feel in their judgment are reasonable and necessary in the diagnosis and treatment of my case.
I acknowledge that no guarantees have been made to me in the result of treatments and examinations done by the providers at Reliant FAS PLLC.
Lab/X-Ray/Diagnostic Services: I understand that I may receive a separate bill if my medical care includes lab, x-ray or other diagnostic services. I further understand that I am financially responsible for any co-pays, deductibles and co-insurance due for these services if they are not reimbursed by my insurance.
Acknowledgment of Responsibility for Payment: I agree to pay Reliant FAS PLLC the professional fees in return for my care. I agree that if the amount of any insurance benefits due to me is insufficient to cover the professional fees of my care that I will be responsible for the payment of the difference, including any deductibles and co-payments. If the insurance coverage is insufficient, denied, or otherwise unavailable. I agree to pay Reliant FAS PLLC all charges not covered my by insurance. I also agree to pay all costs and expenses, including a reasonable attorney or collection agency fee incurred or paid by Reliant FAS PLLC in the collection of this obligation by suit or others.
Original Assignments, Authorizations and Release on File: I permit a copy of the above assignments, authorizations and releases to be used in place of the original which has been filed in the office Reliant FAS PLLC
Medicare Release: I request that payment of authorized Medicare benefits be made on my behalf to Reliant FAS PLLC for any services provided/furnished to me by the providers at Reliant FAS PLLC. I authorize Reliant FAS PLLC to release medical information about me to the Health Care Financing Administration and its agents and any information needed to determine these benefits payable for related services.