I understand that services rendered to me by ENTAAC/CSC are my financial responsibility and that the provider will bill my insurance company as a courtesy. I authorize my insurance company to pay my benefits directly to ENTAAC/CSC and I understand that I will be fully responsible for any outstanding balance on my account.
This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay any patient balance as per my insurance.
The ensure timely settlement of accounts, patients are asked to leave a credit or debit card on file and authorize ENTAAC/CSC to process a charge up to $200.00, for any balance remaining after insurance has processed their claim. ENTAAC/CSC will contact you for approval for any balance greater than $200.00.
I am required to pay my estimated copay, deductible, and coinsurance at the time of service. A service charge of $10.00 will be applied to your account for any co-payment not received at the date of service. I have chosen to assign the benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I authorize the provider to release any information necessary to adjudicate the claim to my insurance carrier. I also understand that should my insurance company send payment to me; I will forward the payment to ENTAAC/CSC within 48 hours. I agree that if I fail to send the payment to ENTAAC/CSC and they are forced to proceed with collections process, I will be responsible for any cost incurred by the office.
BILLING AND COLLECTIONS
You should receive a statement approximately every thirty (30) days unless the charges are pending with your insurance company, or your balance is less than $3.00. If payment or denial is not received by your insurance company within ninety (90) days from claim submission, the total amount due will be your responsibility.
Any amount due remaining after your insurance has paid, denied, or not responding, is expected to be paid in full (by you) withing thirty (30) days unless other financial arrangements have been made with our billing office. Our formal collection process will begin after that time.
SELF-PAY
If you do not have insurance or are having a procedure that is not covered by your insurance, payment in full is expected on or before the date of service.
SURGICAL SERVICES AND PROCEDURES
Surgical Services are not covered at 100% by most insurance plans. Once benefits have been applied, patients are frequently responsible for a deductible, coinsurance and/or co-payment. It is therefore required that prior to surgery, financial arrangements be made to cover the balance due after the insurance company pays its portion. The following plan has been made available for your convenience.
CARECREDIT
CareCredit is a program that offers a line of credit with no interest or low interest payment options. It is “specifically designed for healthcare expenses and makes it easier for you to get the treatment or procedures you want and need. CareCredit is ideal for co-payments, deductibles, treatment and procedures not covered by insurance (CareCredit, Inc.,2005). “ Please visit CareCredit’s website for details at https://carecredit.com/patients/whatis.htm. Restrictions may apply.
RESPONSIBLE PARTY FOR MINORS (18 YEARS AND UNDER)
We assign all financial responsibility to the parent or guardian that completes and signs the patient registration form. Any amounts due at the time of service are expected from the parent or guardian accompanying the minor to the visit. In the event that a divorce decree assigns financial responsibility for medical bills to another individual, we still hold the registering parent or guardian responsible. We will however assist you in the recovering such payment by providing you with receipts showing that payment was made.