I acknowledge full financial responsibility for services provided to me. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including co-payments, coinsurance and deductibles. I understand that under provisions of HIPAA (The Health Insurance Portability and Accountability Act of 1996), my insurance company and/or employer group plan administrator may be notified if I fail to fulfill my financial obligations for the payment of deductibles and coinsurance. I agree to all reasonable attorney fees and collection costs in the event I default on payment of my charges. I also consent that direct payment of authorized insurance benefits are paid on my behalf to Gastroenterology Associates of Colorado Springs, Pikes Peak Endoscopy Center, and/or Anesthesia of the Rocky Mountains.
I acknowledge receipt and review of the Patient Bill of Rights and HIPPA disclosure. I understand the information that has been presented.
By signing below, I acknowledge that I have received, read, understand, and agree to the terms of this Financial Policy and Patient Agreement, Patient Bill of Rights, and HIPPA disclosure. In addition, by signing below, I represent and warrant that I have authority to enter into this Agreement

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent is simply an effort to obtain permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure (if any) for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below you are indicating that you understand (1) the intent of this consent is continuing in nature even after a specific diagnosis has been made and treatment has been recommended; and (2) you consent to treatment at this office or any other satellite office under the common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan, the purpose, and the potential risk and benefits of any test(s) or procedure(s) ordered for you with your physician or healthcare provider. If you have any concerns regarding any test(s) or treatment(s) recommended for you by your health care provider, we encourage you to ask questions.
I voluntarily request that a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, perform reasonable and necessary medical examinations, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I may be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statement and consent fully and voluntarily to its contents.

Patients are responsible for payment of all services provided by Gastroenterology Associated of Colorado Springs, LLP (GACS), Pikes Peak Endoscopy and Surgery Center, LLC, and Anesthesia of the Rocky Mountains, LLC.

The Financial Policy and Disclosure is to help us provide the most efficient and reasonable health care services. Therefore, it is necessary for us to have a Financial Policy and Disclosure stating our requirements for payment for services provided to patients. The center is fully certified Medicare approved and licensed by the state of Colorado. Anesthesia services are provided by Anesthesia of the Rocky Mountains which is owned by the physicians of GACS.

We will file your primary and supplemental insurance for you as a courtesy to you under surgical provisions. However, you need to provide us with complete and accurate insurance information as well as a copy of your insurance card(s).

Although we participate with most insurance companies, it is your responsibility to make sure we are a participating provider with your plan.

Payment is due at time of service. Deductibles and co-insurance amounts applied to the claim will be your responsibility and a deposit for these amounts will be due at the time of service.

Services not covered or deemed not medically necessary by your plan will be billed to you and are your responsibility. You will be responsible for any remaining balance on your account once your insurance has processed our claim.

If referral is required: It is your responsibility to request and obtain a referral from your primary care provider.

If a referral is not in place, you will be responsible for payment or your appointment may be rescheduled until a referral is received from your primary care physician

Procedure prior authorization (if applicable) will be obtained prior to procedure on your behalf. You will be notified of your financialresponsibility prior to the procedure if prior authorization is not approved. Please be aware that pre-authorization by your insurance company does not guarantee insurance payment for services.