• Financial Consent Form

    Financial Consent Form

    Lystra Wilson-Celestine, MD/MPH
  • GCWH is contracted with various health insurance plans, including but not limited to Medicare, and other commercial insurance plans. If your insurance plan is contracted with GCWH, Genesis Center will file a claim on your behalf for the services you receive. If your health insurance is not contracted with GCWH, you are responsible to pay in full at the time services are rendered.

    You should have an agreement with your insurance regarding your financial responsibility for medical treatment. It is important that you understand your insurance coverage. You are liable for any out-of- pocket expenses including but not limited to deductibles, co-insurances, co-pays and/or services not covered by your insurance plan. Some insurance plans also require a prior authorization for a referral. GCWH will help to obtain your prior authorization for referral, however you are responsible to ensure the required authorization is provided in advance. Payment for cosmetic services is due in full at the time of service.

    Depending on your insurance coverage at the time of your visit to the GCWH practice, you may be required to make a deposit on your account before seeing your clinician. Deposits will be applied toward charges incurred but may not fully cover the services you receive. There may be additional charges if more complex services are required for treatment. It is your responsibility to ensure that all services rendered by GCWH on your behalf are paid in full within thirty (30) days of the statement date. Please note that with the exception of errors, GCWH does not change the reason for your services (billing codes) once they have been submitted to your insurance

    Please understand that you are ultimately responsible for the payment of the medical bill. If it becomes necessary for GCWH to collect a payment, you understand that you will be responsible for legal costs, including attorney's fees. You are consenting those payments from authorized Medicare, Government, and any other insurance or third-party benefits can be made on your behalf, and/or on behalf of all members covered under your insurance plan, directly to GCWH for services provided.

    For your convenience, our office accepts most major debit and credit cards. We do not accept cash or checks at this time.

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    A holder of this medical debt contract is prohibited by section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.

     

     

  • Please agree to the terms and conditions below by checking each box*
  • A holder of this medical debt contract is prohibited by section 1785.27 of the civil code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable. 

    A contract entered into on or after July 1, 2025, that does not include the term described above is void and unenforceable

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