Deductible, Co-Insurance, and Co-Payment

If you have health insurance which covers the surgical and/or treatment procedure(s), you are responsible for necessary deductible, co-insurance, and co-payments. Your co-payment is due at the time of service, and co-insurances are settled once the claim is adjudicated. If your deductible has not yet been met, payment may also be required at the time of service.

Non-Covered Services

If services provided are not covered by your health insurance carrier, you will be responsible for necessary payments for those charges not covered.

Out-of-Network Services

As an out-of-network provider and laboratory, and with the potential of utilizing an out-of-network outpatient surgery facility, none of the parties involved have a contract with your health insurance carrier. As a result, you may be financially responsible for a higher share of the fees than a provider, laboratory, or facility within your network.

Insurance Submission

By signing this form, you allow us to contact your insurance company to determine your insurance benefits. The insurance submission process will begin once your visit or procedure has been completed. There are four entity claims that will be submitted to your insurance on your behalf – surgeon, facility, anesthesia, and laboratory (pathology). The insurance may take between sixty and ninety days to finalize all four claims, and possibly longer if an appeal is necessary. Please contact the appropriate parties immediately upon receiving your invoice so that we can begin assisting you with the insurance process.

I acknowledge that I have read and agree to the above Financial Terms & Conditions, and I unconditionally accept the financial responsibilities as outlined above. If additional visits or procedures are necessary, I understand further costs will be incurred, and I am responsible for such costs as outlined above. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a written signature.