INSURANCE SUBSCRIBER INFORMATION
Patient Name: ______________________________________
Chart Number:______________________________________
PRIMARY INSURANCE: _________________________________________________
Subscriber’s Name: _____________________ Relation to patient: ________________
Subscriber’s Address: ____________________________ Phone#: _______________
Date of birth insured: _____________ Grp#: ________ ID#: _____________________
SECONDARY INSURANCE: _________________________________________________
Subscriber’s Name: _____________________ Relation to patient: _________________
Subscriber’s Address: ____________________________ Phone#: ________________
Date of birth insured: _____________ Grp#: ________ ID#: ______________________
RESPONSIBLE PARTY: _________________________________________________
Address: ______________________________________________________________
Home Phone Number: _________________ Work Phone Number: _______________
SS#: _____________________________ DOB: _______________________________
PLEASE NOTE
PAYMENT IS REQUIRED AT TIME OF SERVICE
THERE WILL BE A $25.00 FEE FOR RETURNED CHECKS
FOR YOUR CONVENIENCE, WE ACCEPT ALL MAJOR CREDIT CARDS
I understand that I am financially responsible for all charges and guarantee payment of this account.
I hereby authorize EAR MEDICAL GROUP to release any information required in the course of my examination or treatment for insurance claims. Furthermore, I authorize payment directly to EAR MEDICAL GROUP for medical and/or surgical benefits, which may otherwise be payable to me for their services.
I authorize any physician, hospital, laboratory, or x-ray facility to release to any physician of EAR MEDICAL GROUP any and all medical information hospital record, laboratory studies or x-rays that may be requested. A copy of this authorization is as binding as the original.
Patient / Parent / Guardian name (please print): ______________________________________________
Date: ______________________ Signature: _________________________________________________
Ear Medical Group Financial Policy
It is our office policy to inform you of our patient payment procedure. Please review the section below that is applicable to you, as checked, and initial it.
1 ______ Patient with Insurance. You are responsible for deductibles, copays, noncovered services, coinsurance, and items considered “not medically necessary” by your insurance company. Please pay copayment and coinsurance amounts as services are rendered. The remaining balance should be taken care of 30 days after receipt of payment from the insurance company. If you or your insurance carrier makes payment exceeding your balance, reimbursement will be remitted. If payment cannot be made at each visit, notify the front desk staff to visit with our insurance department.
2 ______ Patient without Insurance (private pay). Please make payment for your care at each patient visit. If payment cannot be made at each visit, notify the front desk to make other arrangements.
3 ______ Worker’s Compensation Patient. As a Worker’s Compensation patient, you may be covered by insurance if your injury is reported at work and verified with your employer. Please be sure to inform the office personnel that injury resulted during employment. The patient is ultimately responsible for the balance due.
4 ______ Personal Injury (accident). If you are a personal injury patient, our office will bill the appropriate insurance companies. If we are unable to obtain payment, the charges for the services rendered will be your responsibility. Please give all information needed for billing. If an attorney is involved and asks you not to submit insurance claims, a doctor’s lien must be signed by you or your attorney.
5 ______ Medicare. Our office will submit your Medicare charges to Medicare and your secondary insurance, if applicable. You are responsible for deductibles, copays, and any noncovered services.
6. We do not participate with ________________________. If we do not participate with your individual insurance, please make payment for your care at each patient visit. If payment cannot be made at each visit, notify the front desk staff and make arrangements with the insurance department.
Guarantee of Payment
________ I understand that I am totally responsible for payment of all fees and services rendered, irrespective of insurance coverage or other responsibilities.
NOTE: The guarantor of each account is ultimately responsible for payment in full of the account. Current, accurate information regarding guarantor and insurance coverage must be provided.
________ I have been advised that if my health insurance carrier / HMO / Medicaid / Medicare plan claims that the services I received today are not considered reasonable and medically necessary for my care, I will be responsible for payment of these services.
________ I understand that if I am participating in an HMO plan, my primary care physician (PCP) must authorize the services that I requested and received today. I have been advised that if I did not notify my PCP in advance for a referral authorization, my HMO plan may deny payment for services and thus, I will become responsible for payment of all services.
________ I have been provided with an overview of the billing process and have read the copy of the “Understanding Your Financial Responsibilities” handout.
ASSIGNMENT
________ I request that payment of authorized Medicare benefits be made on my behalf to Ear Medical Group for any service furnished to me by these providers.
________ The signature below authorizes payment of mandated medigap benefits to Ear Medical Group. Medigap - ____________ Policy Number - ___________ Group Number - ___________
________ I assign the benefits from my insurance carriers to this clinic for the medical/surgical benefits I am entitled.
RELEASE OF INFORMATION
________ I authorize the Ear Medical Group to release to my insurance carrier(s) any information needed to determine benefits or benefits payable for related services.
________ I have read and agree with understanding my financial responsibilities and the payment, policy, assignment, and release of information paragraph stated which apply to me.
X______________________________ ____________________
Patient Date
______________________________ ____________________
Person signing on behalf of patient Relationship to patient
