Please initial in the space provided and sign your name acknowledging your consent and agreement.
If you have insurance, we will provide insurance claim filing for your primary insurance plan with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balanced owed and we expect payment within 30 days from the date we notify you of such determination. It is our policy that we do not take secondary insurance and do not file claims to secondary insurance. It is your responsibility to pay any co-pay, deductible, co-insurance or any other balance not paid for by the insurance or third-party payer within 30 days. Please note all claims must be finalized before any refunds will be submitted for processing. Refund processing can take up to 30 days to issue. For Obstetrical patients all claims including delivery must be finalized.
It is the responsibility of the patient/guardian to provide us with current insurance plan information prior to services rendered in order for accurate billing of services to be filed. You are also responsible for contacting your insurance company to make sure we are in-network with your particular plan. It is your responsibility to know all the guidelines of your plan requirements regarding authorizations, deductibles, co-payments, other vital requirements for all services.
It is the responsibility of the patient/guardian to obtain any referrals that may be required by the insurance company PRIOR to the scheduled visit. Failure to do so will result in the need to reschedule your appointment and a potential $50.00 late notice rescheduling fee may apply.
In consideration of services rendered, you agree to transfer and assign to Celebration Obstetrics and Gynecology all rights, title and interest in any payment due to you or otherwise payable to you for services rendered.