Assignment Of Benefits Financial Agreement Form printable pdf download

ASSIGNMENT OF BENEFITS

FINANCIAL AGREEMENT

SIGNATURE ON FILE

1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Tyler Urgent Care for services

furnished me by Tyler Urgent Care. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE

TO THE Health Care Financing Administration and its agents any information needed to determine these benefits or the release of

medical information necessary to pay the claim. If other health insurance is indicated In Item 9 of the HCFA 1500 form or elsewhere

on other approved claim forms, my signature authorizes releasing the information to the insurer or

agency shown. Tyler Urgent Care accepts the charge determination of the Medicare carrier as the full charge, and I am responsible

only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination

of the Medicare carrier.

2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or

elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request

that payment of authorized secondary insurance benefits be made on my behalf to Tyler Urgent Care, if possible or otherwise to me.

3. RELEASE OF INFORMATION: Tyler Urgent Care may disclose all or any part of my medical record and/or financial ledger,

including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or

corporation (1) which is or may be liable or under contract to Tyler Urgent Care for reimbursement for services rendered, and (2)

any health care provider for continued patient care. Tyler Urgent Care may also disclose, on an anonymous basis, any information

concerning my case, which is necessary or appropriate for the advancement of medical science, medical

education, medical research, for the collection of statistical data or pursuant to State or Federal law, status, or regulation.

4. OTHER INSURANCE: I understand that Tyler Urgent Care maintains a list of health care service plans with which it contracts.

A list of such plans is available from the business office and that Tyler Urgent Care has no contract, expressed or implied, with any

plan that does not appear on the list. The undersigned agrees that I am individual obligated to pay the full charges of all services

rendered to me by Tyler Urgent Care if I belong to a plan that does not appear on the above mentioned list.

5. NON-COVERED SERVICES: I understand that Tyler Urgent Care contracts with health care service plans (i.e., HMOs, PPOs)

state items and services which are “covered” by the health care service plans. Accordingly, the undersigned accepts full financial

responsibility for all items or services which are determined by the health care service plans not to be covered. Examples of non-

covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care

service plan or in the benefit summary the health care service plan furnishes to the patient; and treatment or tests not authorized by the

health care service plan. The undersigned agrees to cooperate with Tyler Urgent Care to obtain necessary health care service plan

authorizations.

6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Tyler Urgent Care, I will pay my

account at the time service is rendered or will make financial arrangements satisfactory to Tyler Urgent Care for payment. If an

account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the

court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged a service fee.

Any benefits of any type under any policy of insurance insuring the patient or any other party liable to the patient is hereby assigned to

Tyler Urgent Care. If co-payments and/or deductibles are designed by my insurance company or health plan, I agree to pay them to

Tyler Urgent Care. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment

of my bill.

7. DIVORCED PARENTS: We do not second party bill. The parent bringing the child to our facility will be

responsible for required co-payments, deductibles etc. at the time of service.

8. PRIVACY PLAN: I agree that I have been given the opportunity to read and receive a copy of the Tyler Urgent Care

Notice of Privacy Practices. this assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is

to be considered as valid as an original.

_____________________________________

______________________________________

___________________

Patient Name (print)

Patient Signature

Date

_____________________________________

______________________________________

___________________

**Parent/Guardian/Representative Name

Parent/Guardian/Representative

Date

Signature

** If an authorization is signed by an individual’s personal representative, the representative’s authority is based on:

_____________________________________

(e.g., state law, court order, etc.)

Assignment Of Benefits Financial Agreement Form

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