12-29-2017 Rector, Suzanne-Rob - Laserfiche WebLink

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PLEASE READ THE FRONT OF THIS FORM CAREFULLY BEFORE YOU COMPLETE ANY OF THIS INFORMATION! CORRI1�f�f�bRp�if��9 Ib:18 AM - Ki NAME i i ADDRESS CITY STATE ZIP SOC. SEC. NUMBER PHONE } EMPLOYER'S NAME EMPLOYMENT ADDRESS CITY PHONE } STATE ZIP TO THE INSURANCE COMPANY lease expedite payment as your insured will continue to receive monthly atements until the balance is paid. Please note the assignment of benefits. hank you. I X . .... ... ..... . I~.��. ... .... . AUTHORIZED. SIGNATURE: _ ..DATE . . utas County WA �I�T�1F7�9N��At�Sf�ll�iCLAIMs 1. If you wish our assistance to filing a claim for your health insurance benefits, please complete the form below and return it to our office. Failure to return the form automatically makes you responsible for payment In full. 2. If you noed another claim filed for a second insurance company, please make a photocopy of the front and back of this statement, then complete one form for each insurance carrier. Return all forms to our office. 3. Be sure to sign the appropriate authorization(s) below for each form submitted. PAT!ENT'S STATEMENT: Complete all items below and return to our office. Insurance Company Insurance Co. Telephone No Claim Office Address Policy Number Group Number Name of Insured _W____- --.Insured D.O.B. Insured Home Phone No. Relation of Patient to Insured Social Security Number Employer of Insured Employer's Address..____ Medicare No. Medicaid No. Employer's Telephone No. Was condition related to ❑ Employment ❑ Auto Accident Date of Accident/Injury Referring Physician -_ AUTHURI7.ATION: I HEREBY AUTHORIZE AND DIRECT MY INSURANCE CARRIER TO PAY DIRECTLY TO THE PROVIDER SHOWN ON THE REVERSE SIDE OF THIS FORM ANY BENEFITS DUE ME UNDER MY 114SURANCE PLAN, I AGREE- TO PAY THE BALANCE OF EXPENSES NOT PAIL) UNDER THIS PLAN, I FURTHER AUTHORIZE THE RELEASE TO MY INSURANCE COMPANY ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. BILLING &,INSURANCE_POLICY You alone, not your insurance company, are responsible for payment of your account, If, after receiving this statement, you are unable to pay in full, you must contact our billing office. if you have reason to believe this billing is incorrect and desire to dispute it, you must notify us in writing within 30 days of receiving this billing. If +roe do not hear from you, we will expect prompt payment of this bill. PLEASE NOTE: There may be a collection charge for checks that are not honored by your bank. Also, there may be an service charge added to past due accounts. We will bill Medicare for you, however, you must provide us with your Medicare number and signed authorization form provided to you at the time of service. If a form was not provided then please sign in the area marked authorized signature above. You will receive a regular monthly billing for any balance owing after payment by Medicare. IF YOU HAVE RECEIVED THE SERVICES OF A HOSPITAL OR OTHER MEMI:CAL FACILITY YOU MAY RECEIVE TWO SEPARATE BILLS. ONE FROM THE HOSPITAL OR MEDICAL FACILITY & ONE FROM. THE PHYSICIAN PROVIDING SERV.IC.ES. THE HOSPITAL OR OTHER MEDICAL FACILITY'S B[LL MAY BE SEPARATE FROM THE PHYSICIAN'S BELL. TOTAL COST ---- HOSPITAL OR MEDICAL FACILMCS FEE PHYSICIAN'S FEE The total cost for many medical services may be comprised of two fees. Each fee may be billed separately by the provider of the services. The hospital or other medical facility's fee covers the cost of providing the technicians, equipment and supplies involved. in performance ofd yo> r service. The physician's fee is for services provided by your physician or for services provided by a physician for the supervision., interpretation and consultation with your personal. physician. The physician .is an independent physician and may not be an employee of a, hospital or medical facility and therefore may bill separately for his or her professional service. DMS -1 GEN 0001