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PtFinancialAcknowledgement

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PtFinancialAcknowledgement Powered By Docstoc
					                           Royal Oaks OB/GYN
                    12121 Richmond Avenue, Suite 414
                           Houston, TX 77082
                      Phone: 281-496-DRVU (3788)
                           Fax: 281-496-3789

PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEGEMENT

1. I understand that full payment is due at the time of service.
2. I understand that co-payments and deductibles are due at the time of service.
3. I have the following options to pay for services: cash, bank debit card,
    MasterCard, Visa, Discover, or American Express. No checks will be accepted at
    this time.
4. Even if I do not have health insurance coverage, I will pay 100% of my
    anticipated charges out of pocket at the time of service.
5. I understand that there are no payment plans.
6. I will provide the most current and accurate information about myself and my
    insurance plan or Medicaid/ Medicare plan. I will update Royal Oaks OB/GYN
    immediately of any changes to my coverage and/or contact information (address,
    phone number, e-mail, etc.). If my insurance/ Medicaid/ Medicare is temporarily
    cancelled, I will call to inform the office of this fact. If I do not notify the office
    of my insurance cancellation and do not show for my scheduled appointments (2
    or more), I authorize Royal Oaks OB/GYN to close my account and chart.
7. I will not give false information about myself or my health coverage plan. I
    understand that I if do this, I will be fired from Royal Oaks OB/GYN as a patient
    and be reported to the authorities/ insurance company.
8. I agree to call and cancel/ reschedule my appointment within 24hours in advance
    if I am unable to keep that appointment. If I do not notify the office of my
    inability to keep my appointment, I agree to pay the full charge of the
    appointment. This charge will be billed to me. I understand that my insurance
    will not cover this charge.
9. I understand that persistent outstanding balances will be turned over to an outside
    collection agency.
10. I will bring my current insurance/ Medicaid/ Medicare card and state/
    government issued picture identification (driver’s license, passport, or
    identification card) to every office visit.

_________________________                                  ________________________
Patient Name (please print)                                Witness Name (office staff)

_________________________                                  ________________________
Patient Signature                                          Witness Signature

_________________________                                  ________________________
Date                                                       Date

				
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