By Marilyn Gard
It is our desire to assist our patients whenever possible.
The following insurance assignment program allows you, our patient, to receive the care
you need without undue financial strain.
1. Waiting for insurance payment is a courtesy provided by
this clinic. We reserve the right to withdraw this courtesy at any time. We will bill your
insurance company and accept assignment of benefits during your corrective care period. We
must receive your completed coverage verification prior to accepting assignment. Direct
assignment will be discontinued when you have finished corrective care and a supportive
health care program is recommended. We will notify you of the change.
2. All deductible amounts must be paid by you in advance of
the first billing. Also, you may stay current with your percentage of responsibility
(usually 20%.) This must be paid at least weekly.
3. The insurance carriers are billed on specific 30-day
cycles. It is your responsibility to supply this office with necessary forms to complete
4. If you receive payment from your insurance carrier
during the period which the clinic has accepted assignment of benefits, you are to bring
the check into this office within one week of receipt and endorse it over to the clinic.
Failure to do this will result in collection action.
5. If you discontinue your care for any reason other than
discharge by the doctor, you will be responsible for any unpaid balance regardless of any
claims submitted to your insurance company.
6. This clinic does not promise that an insurance company
will pay. In the event that the insurance company disputes or rejects the claim, it will
be the patients responsibility to pay the charges and pursue reimbursement from the
I have read the above provisions and wish to participate in
the insurance assignment program. I hereby agree to abide by the provisions of this
program as specified above.
Thanks to Marilyn Gard for the use of her files!