Directions For The Medical Form - Auburn University Medical Clinic Page 2
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3Auburn University Medical Clinic
400 Lem Morrison Drive
Auburn University, AL 36849-5349
TELEPHONE: (334) 844-4416
FAX: (334) 528-6780
E-Mail:
Monday –Friday 8 a.m. – 6 p.m.
Hours of Operation:
Except Thursday 9 a.m. – 6 p.m.
Saturday 8 a.m. – 12 p.m.
(Hours Subject to Change)
INSURANCE INFORMATION
What is the name of your insurance company?_________________________________________________________________________________________________________
Subscriber# _______________________________Group #_____________________________________ Plan #____________________________________________________
What is your insurance company’s claims address ______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Who is the policy holder?____________________________________________________________________Gender: (circle one) M
F
What is your relationship to the policy holder?_________________________________________________ DOB of Policy Holder_____________________________________
Does your plan require a co-payment?___________________ If so, how much? _____________________________________________________________________________
What are the limits (age, full time status, etc.) on the policy for your coverage as a student? _____________________________________________________________________
Does your plan provide for “out of area” coverage for you?___________ Does your plan provide prescription benefits?_______________________________________________
Please attach a legible copy of the front and back of your insurance card. If you have more than one insurance coverage, please
provide both clearly stating which is primary and which is secondary. We will also need each policy holder’s name, date of birth,
gender and relationship to file the secondary insurance.
BILLING INFORMATION
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Patient’s Relationship to billing Person(s):
Self
Spouse
Child
Other
Name of Billing Person(s): _______________________________________________________________________________________
(First)
(Middle)
(Last)
Telephone #s
Home: (_____) -_________-_________ Work: (_____) -_________-_________ Cellular: (_____) -_________-__________
Address: ______________________________________________________________________________________________________________________
(Street / P.O. Box)
(City)
(State)
(Zip)
I hereby authorize Auburn University Medical Clinic (AUMC) to release information from my medical records as may be required or requested by my
insurance company, employer, or any other persons liable to AUMC for payment of all or part of the charges pertaining to my office visits. I also authorize
AUMC to act as my agent when filing insurance claims on my behalf. I directly assign to AUMC all insurance benefits and agree that any benefits
payments sent to me will be promptly forwarded to AUMC. I understand that I am responsible for all charges incurred at the Auburn University Medical
Clinic regardless of the degree to which my insurance covers the services rendered.
Billing Disclosure – If I have insurance, I understand balances will be filed with insurance companies under most circumstances. Items not fully paid or
otherwise accounted for by an insurance company will be billed to me or my designated responsible party. After a period of time, uncollected balances may
be collected through a collection agency including any additional costs related to the collection process. Holds may be placed on my registration/graduation.
Any outstanding balances are my responsibility. If any checks are returned, there will be a “returned check” fee assessed for a minimum of $30.00
and I may be referred to the “Worthless Check Unit” at the Lee County District Attorney’s Office. Failure to comply by these financial policies
and/or recurring instances of collection activity could result in dismissal from the practice.
I understand that some or all of my expenses at Auburn University Medical Clinic may not be covered by my health insurance. I understand and agree to
pay all co-pays at the time of service. I also understand that after 60 days, any patient AND/OR insurance balance becomes my responsibility. You agree, in
order for us to service your account or to collect monies you may owe, AUMC and/or our agents may contact you by telephone at any telephone number
associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text
messages or emails, using any email address you provide to us. Methods of contact may include using prerecorded/artificial voice messages and/or use of
automatic dialing devices, as applicable. If I choose to decline signing this document, I understand that a hold will be placed on my records for Graduation or
Registration until all balances are paid in full. I agree that this agreement pertains to all visits to the Auburn University Medical Clinic. I acknowledge and
understand that at all times I can receive a copy of my patient rights and responsibilities along with a privacy notice on the clinic’s website and the
patient portal. If I do not have internet access, I can receive a printed copy of the patient rights and responsibilities and privacy notice at the clinic.
PATIENT SIGNATURE
DATE
Form: CL-PC-32 Revised 04/13
Page 2
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