Adult Registration Form (Page 2 of 2) in pdf

REGISTRATION FORM

MUST BE COMPLETED USING A BLACK INK PEN

FINANCIAL RESPONSIBILITY

We charge what is usual and customary for our area. Our office policy is that full private payment or insurance co-payment/co-

insurance and/or deductible, as well as, account balances are due at the time of service unless prior arrangements have been made.

The adult accompanying the minor patient will be required to pay in accordance with our policies. Please understand that we will only

bill insurance companies that we are contracted with. Furthermore, it is your responsibility to follow up with the insurance company to

insure the claim is paid within 60 days of the date of service. We must emphasize, that as health care providers, our relationship is

with you, our patient, and NOT with your insurance company. You are responsible for knowing what your insurance benefits are,

including what your insurance will and will not pay for; and how to access your benefits, including obtaining referrals, etc. If you are

unsure, please contact your insurance carrier.

This office assumes no responsibility for your lack of knowledge regarding your

insurance benefits. You are responsible for any remaining unpaid charge(s) as determined by your insurance company regardless of

cause. This agreement is necessary in order to accept your insurance without having to bill you upfront. An account past due 60 days

or more and payment plans that are not kept current may be subject to collection and associated fees. Please note claim information

processed by the insurance company is mailed to the policy holder. If you are not the policy holder for your insurance, the policy

holder (parent, spouse and/or guardian) may receive information from the insurance company pertaining to dates of service and

diagnosis. Melmed Center can not be held liable for information being received from the insurance company.

Please note: Insurance cannot be billed without the patient present.

By completing the information below, you assign your insurance benefits to be paid directly to Melmed Center. You also authorize

Melmed Center to release any information which may be needed for processing all of claims; certification/case management/quality

improvement; and/or other purposes related to the benefits of your health plan. Furthermore, understand that it is your responsibility

to ensure that proper referrals or authorizations are obtained for each visit. Finally, we require notification of insurance changes

at least one week prior to your appointment to avoid appointment delay and/or private pay expenses.

Insurance Company: _______________________ Phone: (

)___________________ Employer: ________________________

Group/Policy#: _________________________ ID#: ________________________ Employee SS#: _________________________

Employee/Insured’s name: ___________________________________________________ DOB: __________________________

Insurance Mailing Address: ___________________________________________________________________________________

Some medications may require Prior Authorization. Please call your insurance company and find out what provider your

PHARMACY BENEFITS are covered through. Please note: This may be located on your insurance card (i.e. Medco, Prescription

Solutions, Caremark, and Express Scripts), if not, we do need this information filled out in its entirety.

Pharmacy Benefit Provider: __________________________

I UNDERSTAND AND AGREE TO ALL OF THE ABOVE_________________________________________ Date __________

Signature of Patient/Legal Guardian

3/26/14 Adult Revision

Adult Registration Form Page 2