RELEASE OF INFORMATION, ASSIGNMENT OF BENEFITS, AND FINANCIAL RESPONSIBILITY
I am requesting medical treatment by the physician at the Rosenberg Cooley Metcalf Clinic. I authorize the release of any medical information necessary for my insurance to process my claim. I understand that I am financially responsible for my bill, and I accept full responsibility for any charges from the physician or physician’s assistant remaining after payment of insurance benefits, and any legal/attorney fees or collections fees (up to 40%) that may be added as a result of nonpayment. I authorize direct payment to my physician at the Rosenberg Cooley Metcalf Clinic.
The specifics of your financial responsibility are included in the Patient Financial Agreement.
As a courtesy to our patients we will file the claim with your insurance carrier with the understanding that the patient/guarantor, not your insurance company is responsible for payment of this account.