Patient Information
Name: _________________________ Date of Birth: _____________
Account Number: _________________ Date: ____________________
Financial Responsibility Agreement
1. Insurance and Payment Policy
- I understand that I am financially responsible for all charges, whether covered by my insurance or not
- I agree to provide current and accurate insurance information
- I authorize the release of medical information necessary to process insurance claims
- Co-payments are due at the time of service
- Self-pay patients must pay in full at the time of service
2. Insurance Coverage
- It is my responsibility to verify that my insurance covers neurological services
- I understand that pre-authorization may be required for certain procedures
- I am responsible for knowing my insurance benefits and limitations
3. Missed Appointments and Late Cancellations
- 24-hour notice is required for appointment cancellations
- A fee of $75 will be charged for missed appointments or late cancellations
- Repeated missed appointments may result in discharge from the practice
4. Payment Terms
- Outstanding balances are due within 30 days of statement date
- Payment plans are available upon request and approval
- A 1.5% monthly interest charge may be applied to overdue balances
- Returned checks will incur a $35 fee
5. Collections Policy
- Accounts over 90 days past due may be referred to collections
- Patient is responsible for all collection costs and legal fees
Acknowledgment
I have read and understand the financial policy and agree to comply with its terms.
Signature: _________________________ Date: ____________________
Print Name: ________________________