ASSIGNMENTS OF BENEFITS
I understand that any quoted healthcare benefits or clinic costs are estimates and not guaruntee of patient responsibility owed amounts.
I request that payment of authorized insurance benefits be made either to me or on my behalf to the Speech & Language Center at Stone Oak ("SLCSO") for any services provided to me by that organization.
I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related services to the organization, insurance carrier or other medical entity.
The following pertains to clients opting not to use their out of network health plan benefits in our clinic, and does not apply to clients who will be using their in network or out of network benefits:
I understand I am electing to NOT USE my health plan benefits at the time of service ("TOS") discounted rate and for which SLCSO is not in network.
I understand that I am agreeing in writing to NOT FILE claims to any health plan in effect at the TOS or within a plan year for any acquired health plan for which SLCSO is out of network.
I understand that should I choose to file a claim at any point after the TOS, then SLCSO would be notified by the health plan, and the family would be obligated to pay to SLCSO the difference between the insurance billed rate and the TOS rate at the point of notification from family's health plan.
I understand that SLCSO would be obligated to file a corrected claim at the insurance rates for the services billed originally as TOS "cash" rate.
A copy of this authorization will be sent to my insurance company or other entity if requested. The original authorization will be kept on file by the organization.