Fillable Financial Payment Policy-Family Medical Center Form printable pdf download

Financial Payment Policy-Family Medical Center Form

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FAMILY MEDICAL CENTER

•

Joel G. Wright M.D.

Clinton D. Damron D.O.

Matthew R. Sampson M.D.

Trina S. Gomm FNP-BC

1492 S. 20

Avenue, Safford, AZ 85546 • Phone: (928) 348-2151 • Fax: (928) 428-3617

Financial Payment Policy

I hereby assign, transfer, and send over to Family Medical Center, PLLC all of my rights, title,

and interest to my medical reimbursement benefits under my insurance policy. I authorize the

release of any medical information needed to determine these benefits. This authorization shall

remain valid until written notice is given by me revoking said authorization. I understand I am

financially responsible for all charges whether or not they are covered by insurance.

I am aware payment is expected at the time of service. Insurance information on file will be

billed first. It is my responsibility to provide FMC, PLLC with changes to or updates in my

insurance coverage. In the event insurance coverage changes and/or an insurance carrier

determine the billed services are not covered, it is my responsibility to contact the insurance

company to clear up coverage denials. Any unpaid amount by the insurance company becomes

my responsibility to pay FMC, PLLC.

In the event no insurance is available, payment for services rendered on my behalf and/or my

beneficiaries becomes my responsibility.

I also acknowledge:

- Applicable co-pays are due at time of service,

- Checks returned to our office for insufficient funds will be assessed a $25 fee,

- Charges for medical records will be due when picked up,

- Unpaid balances after 30 days are considered delinquent, and

- Any applicable collection fees such as delinquent interest, collection agency fees, and

legal/court fees incurred by FMC, PLLC in attempting to collect unpaid balances will

be my responsibility.

Forms of payment accepted are: cash, checks, money orders, debit and credit cards

Responsibility Party Name: ______________________________________________________

Responsible Party SSN: ________________________________

Patient Names: _________________________________ ______________________________

_________________________________ ______________________________

Phone: _________________________________

Email: _____________________________

Address: ___________________________________

PO Box: _____________________

City: _______________________________________State: _________ Zip: _____________

Signature:

Date:

Financial Payment Policy-Family Medical Center Form

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