The following information is provided to avoid any misunderstanding concerning payment for professional services. All professional services rendered are charged to the patient. When supplied with complete insurance information, we will file your insurance for you. The patient is responsible for all fees regardless of insurance coverage. It is customary to pay for services when rendered unless prior arrangements have been made with our business office. We are participating providers with Medicare, therefore, claims will be filed by Texas Regional Physicians and payment will be received at this office. A copy of this authorization and assignment shall be considered as valid as the original.

You understand that you are responsible for your account balance regardless of what any insurance pays. You hereby authorize Texas Regional Physicians to furnish information to my insurance carrier and/or attorneys concerning my treatments. You hereby assign to Texas Regional Physicians all payments for services rendered to myself and/or my dependents.

• As a courtesy, we will file your primary and secondary insurance. We do not file third insurance.
• All charges for treatment become due and payable within thirty (30) days after your insurance payer has evaluated and processed your claim at which time you are responsible for any remaining balance.
• We will require payment of your co-pay and/or deductible & applicable co-insurance at the time services are rendered.
• The patient acknowledges that it is the patient's responsibility to be aware of what services are covered and agrees to pay for any services deemed to be non-covered or not authorized by their plan(s):
• Medicare - We accept assignment. Please pay your 20% or allow us to file your supplemental policy. If you do not have a supplemental policy, we will ask you to pay the Medicare Deductible/Co-Insurance Medicare and secondary carriers do not cover some procedures or supplies. Please make sure you understand which treatments and supplies are covered as you will be asked to sign a waiver stating that you understand when services are deemed not covered and you will be responsible for associated charges.
• HMO's -It is the patient's responsibility to get referrals for visits. Patients seen without the requisite referral will be responsible for charges in full at the time of service.
• Self-Pay - If you do not currently have insurance coverage, we ask that you coordinate payment prior to your visit. We do require payment in full at the time of service unless prior arrangements have been made.
• All Payers - it is the patient's responsibility to verify that we are participating providers with your health plan. In the event that we do not participate with your plan, we will file your claim as a courtesy but you will be responsible for full payment for services rendered at the time of the visit.
• We may charge you a "No Show" fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date/time.
• Insufficient fees on returned checks will be $25.00.

In consideration of the services provided, the undersigned agrees to be personally responsible for all charges incurred at Texas Regional Physicians in accordance with the clinic’s standard rates and terms, regardless of whether insurance benefits are available or ultimately paid on my behalf. If it becomes necessary to refer my account to an attorney or collection agency for collection, I understand that I am responsible for all associated fees.

In consideration of the services rendered to the patient, the undersigned authorizes direct payment of all insurance benefits to Texas Regional Physicians that would otherwise be payable to me. I hereby transfer and assign all rights, title, and interest in the insurance benefits listed above, including but not limited to copayments, deductibles, out-of-pocket expenses, charges exceeding policy coverage, and any limitations or exclusions under my policy.

Texas Regional Physicians may release health information to your insurance company or any entity responsible for processing claims to determine coverage and facilitate payment. No additional consent from me is required for this disclosure.

I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS AGREEMENT AND THAT I AM THE PATIENT, THE PATIENT’S PARENT OR LEGAL GUARDIAN, OR AM OTHERWISE AUTHORIZED TO ACCEPT THESE TERMS ON THE PATIENT’S BEHALF.