Tsung & Virmani Medical Group, Inc.
PAYMENT:
You are responsible for the
full payment of all services rendered which includes appointments as well
as physician time spent on your behalf for items such as records review, phone
calls, communication with specialists, filling out forms, writing letters,
etc.
We cannot bill
Medicare for our patients since our office has opted out of Medicare. Medicare patients cannot submit any claims to
Medicare but may try to send a claim to secondary insurances that are not
Medigap plans. Patients with PPO
insurance will receive an insurance claim form which you may submit to your
insurance if you wish to receive possible reimbursement. Please note that not all services are covered
by all insurance contracts. Moreover,
many insurance companies will pay a percentage based on the “usual and
customary fee” that is determined independently by each insurance company and
may not be the lower than our fee.
Contact your insurance company to find out what benefits are covered or
excluded under your plan.
NON-COVERED SERVICES:
If we provide services that
are not covered by your health plan, you will be responsible for payment in
full for those services. Your signature
below constitutes agreement to pay for such services even if not covered by
your insurance. No matter what type of
plan you have it is your responsibility to know and understand your
coverage. Contact your insurance company
to find out what services are covered or excluded.
In case you become
hospitalized or have services beyond the usual office visit, signing below
authorizes Tsung & Virmani Medical
Group, Inc. to release any medical information necessary to process
insurance claims on your behalf and to request that a PPO insurance make
payment directly to Tsung & Virmani
Medical Group, Inc.
LATE CANCELLATIONS:
The office may elect to
charge the full fee of the visit if you cancel either a new patient consult or
physical with less than 1 week notice or cancel a follow up appointment with
less than 48 hours notice.
MEDICAL RECORDS:
The law requires that we have
a signed written request to copy a patient’s chart. We require a two-week notice. There is a fee (depending on amount copied)
that must be collected prior to releasing the medical records.
AUTHORIZATION FOR
CREDIT CARD CHARGES:
I hereby authorize Tsung
& Virmani Medical Group, Inc. to charge the card listed below for medical
services including scheduled appointments and physician time spent on my
behalf for services such as records review, communication with specialists,
researching topics on your behalf, filling out forms, writing letters,
preparing paperwork for insurance authorizations, etc.
Thank you for choosing Tsung & Virmani Medical
Group, Inc.
Patient’s Signature: __________________________ Date:
_______________
Print Name:
________________________________
or
Signature of Authorized
Representative
for the
above patient: _________________________
Date: _______________
Print Name:
________________________________
Credit Card Information for New Patient
Registration
NAME: ____________________________________
BILLING ADDRESS: _________________________________
ZIP: _______
CARD #: ________________________________________
(Visa/Mastercard
only; we do not accept American Express)
EXPIRATION DATE: _______________________________
V Code (3 digit code): ______________
Time spent by the doctor for medical services will be recorded. Please call us if you require a copy of the log.