Financial Policies

Financial Policies 2017-08-31T12:57:23+00:00

Financial Policies

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  • IF YOU HAVE YOUR INSURANCE CARD, YOU ONLY NEED TO SIGN BELOW AND HAND YOUR CARDS TO THE RECEPTIONIST. IF YOU DO NOT HAVE YOUR INSURANCE CARD PLEASE PROCEED TO FILL OUT THE INFORMATION BELOW.
  • NO INSURANCE / SELF PAY - Please read, sign and fill in ALL info
    Financial responsibility: I agree that in return for the services provided to the patient by GB Family Care, I will pay the account of the patient prior to discharge or make financial arrangements satisfactory to GB Family Care for payment. If the 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 jury in any court action. A delinquent account may be charged interest at the legal rate. I further understand that there may be additional charges for x-rays and lab tests performed by providers or organizations other than GB Family Care that will be billed separately.
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  • ASSIGNMENT OF BENEFITS
    I certify that I (or my dependent) have insurance coverage and I authorize, request and assign my insurance company to pay directly to GB Family Care insurance benefits otherwise payable to me. I understand that I am financially responsible for all charges whether or not paid by the insurance. I hereby authorize GB Family Care to release all information necessary, including the diagnosis and the records of any exam or treatment rendered in order to secure the payment of benefits. For any Medicare eligible coverage, I request that payment of any authorized Medicare benefits be made payable on my behalf to GB Family Care. Any insurance of any type under any policy of insurance insuring the patient or any other party liable to the patient is hereby assigned to GB Family Care to the rendering service for application to patient's bill. I authorize the use of this signature on all insurance claims, including electronic submission.
  • Date Format: MM slash DD slash YYYY