Patient Responsibility Statement
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND BE SURE THAT YOU UNDERSTAND EACH OF THEM CLEARLY. SIGN AND DATE THIS FORM IN THE SPACE PROVIDED.
• If my medical insurance policy requires that an approval and/or written referral be obtained before each and/or any medical service is rendered, I understand that I am personally responsible for obtaining all required prior approvals and/or referrals for any and all medical services rendered by Alan E. Oshinsky, M.D., P.A. Further, I personally agree and understand that I am fully financially responsible for charges incurred for
medical services without such approvals and/or referrals. I also understand that I am personally responsible for knowing the status of my referral, i.e. the nature of the medical service allowed, the number visits authorized and the expiration date.
• I understand that I should review my EXPLANATION OF BENEFITS when received to help determine my financial responsibility for services rendered.
I know and agree that I am financially responsible for payment of deductibles and/or copay amounts as outlined by my healthcare plan.
• I understand and agree that I am fully financially responsible for payment of charges for all services rendered and not covered for any reason, whatsoever, by my healthcare plan, which charges I agree are fair and reasonable.
• I understand that I will be charged $50.00 for any appointments not cancelled within 24 hours prior to my visit.
• I understand that I will be charged $35.00 for any checks returned by the bank for insufficient funds.
• I understand that I should direct all questions concerning my insurance plan and benefits to my healthcare plan representative.
• I understand and agree that if my insurance changes, I must notify Alan E. Oshinsky, M .D., P.A. in writing of such change and that I must submit correct information which will allow for correct billing. If I receive medical service without prior notification of insurance change or
incorrect notification, I agree and understand that I am fully personally responsible for payment of all charges for medical services rendered.
• I authorize any entity or agency to release any and all medical records required for the management of my medical condition.
• All payments are expected at the time of service and any outstanding balances are due within 30 days.
All past due balances are assessed a 1.5% per month (18% per annum) finance charge.
All balances that reach 90 days past due will be sent to a collection agency.
If it becomes necessary to send my account to collections, I agree and understand that I will pay for all collection costs and reasonable attorney fees on the unpaid balance owed, but in no event less than $50.00.
I understand and agree that I will pay for all court costs and the costs of a private process server, if necessary.
• I agree and understand that Alan E. Oshinsky, M.D., P.A. charges a $10.00 completion fee for any forms that need to be completed. These forms include, but are not limited to, school, camp, sports participation, FMLA, life insurance, disability. I understand that I need to allow five business days for completion.
• I authorize treatment by Alan E. Oshinsky, M.D., P.A. and agree to be responsible for my bill. I authorize my insurance benefits to be paid directly to Alan E. Oshinsky, M.D., P.A. I also authorize disclosure of my medical records to any agency involved in payment for my treatment. I consent to have Alan E. Oshinsky, M.D., P.A. to act as my authorized representative for the purpose of accessing and transmitting my
coordination of care document.
