consent for Medical Vein Clinic to electronically obtain my medical history. Medical Vein Clinic will use this information for reference and make sure any medications prescribed will not interact with medications I may be taking.
Patient Financial Responsibility
Thank you for choosing Medical Vein Clinic as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of your visit, the financial responsibility for payment is yours.
If you have had any changes in your insurance coverage - even if there is only a small change in the copayment amount or a change in the expiration date of the policy - you must notify us. Even a small discrepancy on the form can lead to a claim denial.
We emphasize that as a medical care provider, our relationship is with you and not with your insurance company. It is your responsibility to know your policy. Again, we thank you for choosing Medical Vein Clinic as your healthcare provider and are here to help you!
We will bill your insurance as applicable, however, you are ultimately responsible for any fees and costs not covered or paid by your insurance. Questions about non-payment should be directed to your insurance company.
If you are unable to keep your scheduled appointment, we ask that you give adequate notice; so that we may open your reserved time for another patient. This helps us stay efficient in our office, but most importantly helps our patients on our “waiting list” and to our staff as well.
Short Notice or “No Show” Cancellations may be charged the following fees:
- $25.00 for Consults / 24 hour notice required
- $50.00 for Ultrasound Studies / 3 days notice required
- $50.00 for Sclerotherapy / 3 days notice required
- $100.00 for Procedures / 3 days notice required
Please know, each appointment cancelled that falls within this timeframe, can be reviewed and waived by management, due to extenuating circumstances not within your control. If the appointment is missed without proper notice of cancellation, the fee becomes non-refundable.
This is an agreement to accept our services. We will attempt to collect unpaid balances for a period of 30 days and upon no agreement reached, the unpaid debt for our services will be transferred to our collection agency, The Phoenix Recovery Group, and will be subjected to additional fees and expenses for that process. In the case your account is forwarded to the collection agency, you may no longer be a patient at this office.
INDIVIDUAL’S FINANCIAL RESPONSIBILITY
I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.
Co-payments, co-insurance, and/or deductibles are due at the time of service.
If my plan requires a referral, Medical Vein Clinic will do our best to obtain with the first request; but ultimately may need your assistance with follow-up.
In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided (Medicare exclusions apply).
If I am uninsured, I agree to pay for the medical services rendered to me at the time of service.
INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to Medical Vein Clinic on my behalf for any services furnished to me by the providers.
AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Medical Vein Clinic to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.
MEDICARE REQUEST FOR PAYMENT
I request payment of authorized Medicare benefits to me or on my behalf for any services furnished to me by or in Medical Vein Clinic. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THE PATIENT FINANCIAL RESPONSIBILITY FORM.
