Patient Financial Obligation - Lemont Ent Sc (Page 2 of 2) in pdf

Cynthia Go, MD, PhD, FACS

1011 State St, Ste. 120, Lemont, IL 60439 – (630) 243-4505 (Phone/Fax)

PATIENT FINANCIAL OBLIGATION

I authorize the provider to act as my agent in helping me obtain payment from my insurance companies. I

understand the provider does not accept responsibility of collecting my insurance claims or for negotiating

a settlement on disputed claims.

I assign all rights and claims for reimbursement of expenses allowable under my insurance plan and

authorize payment directly to the provider for services rendered. I understand I will receive a total of two

statements for any balance due by me before a mandatory full payment letter is initiated by Lemont ENT,

SC.

I agree to pay an unpaid balance due and owing on my account within THIRTY (30) DAYS from the date of

the initial statement.

Further, I agree than any portion of my account which remains unpaid after the passage of SIXTY (60)

DAYS from the date of the first monthly statement shall be considered “delinquent” for the purposes of

collection and shall bear interest at a rate of FIFTEEN PERCENT (15%) per annum until paid in full.

If any portion of my account becomes delinquent and it becomes necessary for the provider to refer this

matter to an attorney for collection, I agree to pay the reasonable attorney fees, costs and expenses

incurred through and/or other efforts to collect the delinquent sums.

I authorize Lemont ENT, SC to charge the credit card information provided below for any

outstanding balances remaining after the visit claim has been processed by my insurance company.

I also understand that a $25.00 charge will be applied for any no-show appointments.

Name on Card: ________________________________________________________________________

Credit Card Type: _____ Visa

_____ Mastercard ____ Discover _____ AmEx

Credit Card Number:

Expiration Date: ______/______ 3 or 4-digit CVV code on back:______________

___________________________________________

___________________________

Patient Signature

Date

Printed Name of Parent or Guardian

Lemont ENT, SC

Cynthia Go, MD, PhD, FACS

Patient Financial Obligation - Lemont Ent Sc Page 2