Form

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IMPORTANT INSURANCE INFORMATION

Insurance processing can sometimes be confusing. We are providing this information in an effort to assist you in understanding our verification process.

When the need for surgery is determined by the physician the patient’s chart and procedure information will go to the insurance department. The insurance department will then verify your benefits. We confirm that the procedure code the physician will be using is covered by your plan. If it is not covered we will notify you immediately.

If pre-certification and/or pre-determination is required we can often provide the required information over the telephone, however, on occasion we will have to mail or fax this information to them.

When your insurance provider responds to the above questions our insurance specialist will calculate the estimated amount due from you based on your co-payment and deductible. Note:This is an estimated amount, the actual amount may vary.

Completion of this verification procedure could take from two to four weeks and even longer in some cases. We will notify you before scheduling your surgery with the estimated amount of your out-of-pocket expense for the surgery or procedure.

Payment of your estimated amount will be due before your surgery, to be paid at your pre operative visit. We accept personal check, VISA, Master Card, Care Credit, as well as cash.

It is important that you note that your insurance provider will not promise payment for any procedure. Payment for these benefits is subject to eligibility at the time of service and all contract limitation on your policy. Should your insurance provider elect not to cover this surgery or procedure you will be responsible for any charges incurred upon our receipt of insurance denial.

If you have any questions please call your insurance company. I have read and understood the above and agreed to meet my financial obligations.