I hereby direct my insurance carrier to make payments directly to the Provider for health insurance benefits otherwise payable to me, but not to exceed the Provider's regular charges. I understand that I am financially responsible for charges not covered by this authorization (including co-payments and deductibles that are due at the time of service). The assignment of benefits shall be valid for the duration of my treatment.
I hereby authorize the Provider and his/her office & billing staff or agency to release billing and medical information to person(s) involved in my care or to the insurance company necessary to process claims for services rendered to me by the Provider. This authorization is limited to the release of information necessary to substantiate and process health insurance claims and excludes such confidential information which by law may only be released by specific consent.
If I need to re-schedule or cancel an appointment, I will call at least 24 hours before the appointment. In case of "Late Cancellation" or "No Show", I agree to pay a fee of $75 per appointment.
Providing credit or debit card information is completely voluntary and is not required to register as a patient.
I give my permission for the HKD Outreach PC to charge my credit/debit card or HSA card for services rendered. I understand that in giving my permission, my noted account will be charged the full agreed upon fee/patient responsibility due, normally within a week of when services were rendered.
I agree to notify the HKD Outreach PC in writing of any changes in my account information or in the event that I choose to withdraw authorization for recurring payments. I also understand that if a payment is returned for Insufficient Funds, the HKD Outreach PC may attempt to process the charge again, and I agree to any additional applicable charges added to the full amount due as reimbursement for any incurred fees.
By providing my signature (on paper or electronic) to this document I am attesting that I understand and accept the above stated terms and I hereby authorize the HKD Outreach PC to charge my below listed card for recurring payment for services provided.
Card Details
Important Notice:
If your insurance including Medicare & Medicaid doesn't pay for the services mentioned below, you may have to pay. Your insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need.
| Services | Reasons Insurance May Not Pay |
|---|
| In-patient and/or out-patient medical & psychiatric services including rehab services. | Member's plan's status. Member's benefits limit. Services not covered under member's plan. Any other. |
What You Need To Do Now:
- Read this notice, so you can make an informed decision about your care.
- Ask us any questions that you may have after you finish reading.
- Choose an option below about whether to receive the Services listed above.
This notice gives our opinion, not an official Insurance decision. If you have other questions on this notice or billing, call your insurance at the number on the back of your Insurance Card.
Signing below means that you have received and understand this notice.
