Patient Registration Form

We are committed to providing you with quality care, and your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibilities as our patient. It is your responsibility to contact our office to notify us of any changes to your information, such as a change in address, telephone number, or insurance information.

You must complete and sign our Patient Financial Policy before care is rendered.

Please provide us with your current insurance information at the time of scheduling each visit and notify us of any changes. We must be able to verify your eligibility prior to your visit or your appointment may be re-scheduled. We will scan a copy of your insurance card and photo ID to copy and keep on file for our records in accordance with insurance plan requirements.

Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility as the Policy holder/Patient to understand the coverage and benefits and be knowledgeable of any deductibles, copayments and/or coinsurance.

It is the Patients responsibility to be sure your doctor is in-network, and the services are covered under your plan. If your doctor is out-of- network, you will have a higher out of pocket cost. If your insurance requires a referral, it is your responsibility to provide the referral to our office prior to seeing the physician. If unable to provide the referral prior to the visit payment in full will be required at the time of the visit. If you have any questions regarding your current insurance policy benefits you should contact your insurance plans’ Member Services.

• Payment is due at the time of services, including copayments, past due balances, deductibles, and coinsurance as applicable. For your convenience we accept cash, checks or credit cards.

• Self-pay patients are those patients without insurance coverage or are receiving a service not covered by their Plan. Self-pay patients are required to pay for any charges at time of service. Self-pay rates are dependent upon the service being provided. For more information ask the office manager.

• We file insurance claims as a courtesy to our patients. Your insurance company may need you to provide certain information directly to the insurance company. You are responsible for complying with their request.

• There is a $50 fee for all returned checks.

• Our office policy is to require at least 24 hours’ notice of cancellation of a booked appointment. Failure to provide adequate notice will result in a missed appointment fee of $50.

• If your insurance company denies payment because of benefit limitations or noncovered services, you will be responsible for the charges.

• We will bill your health plan for all services provided in the hospital. Any balance due is your responsibility and is due upon receipt of a statement from our office.

• Any after-hours calls the patient requests the answering service places to the physician on call that is not deemed a true emergency by the physician may result in a $50 charge to you. This charge will not be covered by insurance and will be patient responsibility.

• Should you need a copy of your medical records, please fill out our medical records release form to authorize the release of records and designate a recipient. Charges to complete medical forms and patient-requested letters are not covered by insurance and are therefore the responsibility of the patient. Fees vary according to the length and complexity of the records requested, patient form or patient-requested letter and are determined by management.

Nonpayment. Please be aware that if a balance remains unpaid without partial payments, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Financial Hardship & Payment Plan. If other arrangements need to be made, please speak with the receptionist prior to yourvisit.

Assignment of Benefits. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plans. I authorize any insurance company to pay benefits due directly to Texas Lung Care Associates and to release to my insurance carrier any medical records or documents requested to secure payment. This assignment will remain in effect until revoked by me in writing.

Medicare Release & Assignment of Benefits. I authorize any holder of medical or other information about me to be released
to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I permit a copy of this request for payment of medical insurance benefits either to myself or the party who accepts assignment.