Tsung & Virmani Medical Group, Inc.

 

PATIENT FINANCIAL RESPONSIBILITY DISCLAIMER & ASSIGNMENT OF BENEFITS

 

 

PAYMENT:

You are responsible for the full payment of all services rendered on the day of the office visit.  We cannot bill for our Medicare 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 a copy of our bill which you need to submit to your insurance if you wish to receive possible reimbursement.  Please note that not all services are covered by all insurance contracts.  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 same as 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.  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.

 

ASSIGNMENT OF BENEFITS

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.

                                                      

COLLECTIONS:

If it is necessary to assign your account to a collection agency and/or attorney, you will be responsible for all associated fees and costs.

 

MEDICAL RECORDS:

The law requires that we have a signed written request to copy a patient’s chart.  We require a one-week notice.  There is a fee (depending on amount copied) that must be collected prior to releasing the medical records.

 

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. 

 

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:  ________________________________