Tsung & Virmani Medical Group, Inc.






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.



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.



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. 



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.



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:  ________________________________


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.