Insurance Information: (Please have your insurance card(s) available to be copied
Assignment Of Benefits I hereby assign payment directly to Georgia Vascular Specialists, PC, all medical benefits otherwise payable to me under terms of my insurance contract as payment towards the total charges for professional services rendered. I understand that I am responsible for charges not covered under this assignment. I also understand it is my responsibility to inform this office of any change in my health insurance.
The undersigned agrees they are jointly and severally liable for the payment for any service, medications, or other items provided to the patient. The acceptance of insurance by this office is a courtesy and shall not act to amend nor void your obligation to pay the balance due. All obligations are due and payable upon receipt of statement. If any amount due shall require collections by or with the assistance of an attorney the undersigned shall be additionally responsible for all attorney's fees, court costs, or other expenses of collection, not less than 15% of the balance at the time of placement for collections.
Authorization to Release Information: I hereby authorize Georgia Vascular Specialists, PC to release to my insurance company any medical information or any other information requested by the insurance company to ensure payment.
Responsibility of Patient: I do hereby expressly guarantee payment in full on any and all claims and charges in consideration for medical services rendered or to be rendered to the patient. All delinquent accounts will be subject to payment of costs or reasonable collection fees and attorney's fees.
I understand that a $40.00 no show fee may be applied to my balance for any Office visit appointments that are missed without rescheduling or cancelling within 24 hours of my appointment.
I understand that a $50.00 no show fee may be applied to my balance for any Lab visit appointments that are missed without rescheduling or cancelling within 24 hours of my appointment.
I understand that a $75.00 no show fee will be applied to my balance for any OIC procedure that is missed without rescheduling or cancelling within 72 hours of my appointment, or
Iunderstand that a $250.00 no show fee will be applied to my balance for any OIC procedure that is missed without rescheduling or cancelling within 24 hours of my appointment, or
Privacy Practice Acknowledgement: I have been provided the opportunity to view and receive a copy of the Notice of Privacy Practices.
By signing below, I agree to the terms of this agreement.