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Financial Agreement - CX/NS Policy

Your clear understanding of our Financial Policy is important. Please ask if you have any questions about our fees, financial policy, or your financial responsibility. Patients must fill out all forms prior to being seen. WE WILL REQUEST TO PHOTCOPY YOUR INSURANCE CARD(S) AND A PHOTO ID FOR YOUR FILE.

By signing the Electronic Signature Acknowledgment and Consent Form, I confirm that I have read this agreement, understand it, and acknowledge that the electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

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Please INITIAL below by each item, verifying you have read and understand our financial policies.
APPOINTMENTS – See the About Appointments Form regarding no show/cancellation fees associated with each appt.
REFFERALS/AUTHORIZATIONS –  If your plan requires a referral from your PCP, it is YOUR responsibility to obtain it prior to your appt and have it in our office at the time of your visit. If you do not have your referral, you will not be seen, cancellation fees will apply, or you can sign a financial waiver to be set up as a “Self-Pay” patient and you will be personally responsible for that day’s services. Authorizations: Decisions can take up to 15 business days. *
CO-PAYMENTS –  By law, we MUST collect your carrier-designated specialist co-pay. This is due at the time of service. Be prepared to pay the co-pay at each visit. Any procedure performed in this office should be deemed medical by your insurance company and all copays and deductibles apply.
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FMLA AND/OR WORKMANS COMP – There is a $50.00 charge for completion of Workman’s Comp, FMLA, and any other request for forms to be completed by our staff. *
IN/OUT OF NETWORK PLANS –  You will be responsible for any balance your plan indicates as due on their explanation of benefits form. We will adjust the charges to coincide with your plan’s UCR (Usual, Customary and Reasonable) charges. All patients will be responsible for their co-insurance and deductible. If we do not “participate” with your plan, you will be responsible for the full amount due. (**Private Insurance authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to MDBI for any services furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any holder of medical information about me to release to my insurance company (or the agent) information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.**)
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NO SURPRISES ACT –  As a courtesy, we do verify your insurance to check in and out-of-network benefits as well as to determine if our testing and treatment is covered by your insurance. Once we obtain this information, we will use medical software to produce a cost estimate based on what your insurance has told us. This is JUST AN ESTIMATE and is never a guarantee of payment by your insurance. Insurance plans can adjust the rates at will and this is out of our control. We will do our very best to provide you with the most accurate cost estimate possible.    .
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MEDICARE ONLY – We submit claims to Medicare. The patient will be responsible for the deductible and 20% co-insurance, which can be billed to secondary insurance. (*Medicare Lifetime Signature on file: I request that payment of authorized Medicare benefits be made on my behalf to MDBI for any services furnished to me. I authorize any hold of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This info will be used for the purpose of evaluation and administering claims of benefits.*)
SELF-PAY PATIENTS – Payments is expected at the time of service.
DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – The parent who consents to the treatment of a minor child is responsible for payment of services rendered, Midwest Dizziness and Balance Institute will not be involved with separation or divorced disputes.
INSUFFICIENT FUNDS CHECKS –  A $25.00 fee will be charged for checks returned due to non-sufficient funds.
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NO SHOW FEES/POLICY – I understand there are fees associated with no showing or cancelling appointments without 48 hr notice: $40 case history call, $200 Full Evaluation, $100 BPPV appointment, $35 first AVT, $50 2nd or add’l AVT’s.

You are responsible for the timely payment of your account. We reserve the right to send your account to collections in the of nonpayment. Thank you for taking the time to review our policies


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By signing this form, I agree that my name and initials provided above and below acknowledge my receipt and review of the financial policy. Payment is expected at the time of each appointment and can be via check, debit or cash, without any transaction fees, but please note, there is a 3% transaction fee for credit card use. This fee doesn't apply to HSA/Debit

Patient Name (Electronic Signature):
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Date: *
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