PATIENT RESPONSIBILITY FORM

1. INDIVIDUAL’S FINANCIAL RESPONSIBILITY

• I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.

• Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit. 

• In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.

• If I am uninsured, I agree to pay for the medical services rendered to me at time of service.

• I understand that I will be charged $40 for appointments not cancelled within 24 hours.

2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

• I hereby authorize and direct payment of my medical benefits to New Leaf Adult and Women’s Health NP, PLLC on my behalf for any services furnished to me by the providers.

3. AUTHORIZATION TO RELEASE RECORDS

• I hereby authorize to New Leaf Adult and Women’s Health NP, PLLC to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to another medical provider

4. MEDICARE REQUEST FOR PAYMENT

• I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in to New Leaf Adult and Women’s Health NP, PLLC. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.