Insurance Disclaimer Patient Responsibility Acknowledgement

Insurance Disclaimer:

“A quote of benefits and/or authorization does not guarantee payment or verify eligibility.  Payment of benefits are subject to all terms, conditions, limitations and exclusions of the member’s contract at time of service.”

Insurance Liability for Payment: 

Your health insurance company will only pay for services that it determines to be “reasonable and necessary.”  Every effort will be made by this office to have all services and procedures preauthorized by your health insurance company, when applicable. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service.  We suggest to all patients that they contact their insurance company to confirm that these services are covered.

Under this arrangement, you are responsible for paying your co-pay, any non-covered portions and any deductible you have yet to cover.  In addition, if your insurance company does not pay for our services, you agree to pay for the services provided in our clinic.

 I understand that my health insurance company may deny payment for the services identified above, for the reasons stated.  If my health insurance company denies payment, I agree to be personally and fully responsible for payment.  I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies.

By typing your name above, you are agreeing to the above statement

Thanks for submitting!

Please return to the

New Patient Paperwork section

to continue completing your child's paperwork