FEES AND INSURANCE INFORMATION
All fees are payable at the time services are rendered. We accept Visa, Master Card and American Express. Your medical insurance is a contract between you and your insurance carrier and the terms of the contract vary according to the terms of the policy. Final payment for all charges is the patient’s responsibility and should it be necessary for this account to be turned over to either an attorney or collection agency for collection, I understand that I will be liable for any charges incurred, including attorney’s fees and court costs.
Todos los honorarios por servicio deben ser pagados al recibir el servicio. Aceptamos Visa, Master card y American Express. Su seguro medico es un contrato entre usted y su compania de seguro. Pagos por nuestros servicios dependen de los terminos de su poliza. El pago final de todos los cargos es su reponsabilidad. Si es necesario tomar accion legal para cobrar esta deuda, usted es responsable de los gastos legales.
PHYSICIAN’S RELEASE AND ASSIGNMENT
I hereby authorize payment directly to the physician of all benefits applicable and otherwise payable to me from my insurance carier, HMO or other third party, payor, for services rendered by the physician. I understand that I am financially responsible to the physician for any and all charges that the carrier declines to pay. I hereby authorize the release of my medical records as deemed necessary for payment of insurance benefits.
Por la presente autorizo el pago directamente a el medico todos los beneficios derivados del seguro que ampara al paciente y que normalmente yo tendria derecho de percibir. Con mi firma autorizo tranferir documentos relacionados a mi tratamiento medico a mi compañia de seguro para procesar mi reclamacion. Yo entiendo que soy responsable por todos los cargos no cubiertos bajo mi seguro medico.
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