In EII Stephen M. Asmann, M.D Memory Crowley, D.O. Christopher Cuzik, D.O. Cary M. Winfrey, D.O. Kelley Winfrey, D.O. Sherri Sartin, PA-C Carol Takis, PA-C Russell Kane, PA-C Clermont Medical Center FAMILY PRACTICE Patient's Name (Last) Marital 11single DMarried ls this your primary lf not, list other address? _. o Yes address: _ I No of Employer (Guardian/Parent's Employer if a Minofl Name of Spouse/Parent How did you hear about us? D yellow , address pages I lnsurance Company B Other (Please give us name/address of friend/doctor, etc.) and phone no. of contact in case of emergency lf other than patient, name and address of person responsibG foithG accountHOW DO YOU PLAN TO PAY FOR TODAY'S VISIT? Please check appropriate box(es) A African D Native American O Hispanic O Mediterranean I Asian American J Caucasian il Northern European D Other I hereby give consent to Clermont Medical Center to provide whatever treatment they deem necessary to the patient above I certily that the information I furnish is true and correct. I know it is a crime to {ill out this form with facts that I know are lalse or lo leave out facts I know are important. my insurance carrier or its intermediaries to issue payment check(s) direct to the physician(s) rendering the covered services for the next 12 month plriod. I hereby authorize Clermont Medical Center to turnish complete inlormation requested by my insurance carrier or its intermediaries regarding services rendered. balances. I request that payment ofauthorized Medicare/i,/edigap benefits be made either to me or on my behalf to Clermont Medical Cenler for any services furnished me by that physician. I aulhorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any inlormation needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay lhe ilaim. lf ,other health insurance" is indicated in item g ot the HCFA-'1 500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. ln liledicare assigned cases, the physician or supplier agrees to accept the charge determination;f the medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. BENEFICIARY SIGNATUBE C07535 Page 1 ol 2 (12113) I hereby authorize the physician to release any information, including Hlv results, acquired in the course of my treatment necessary to process claims. CLE RMO|YT MEDICAL CE \YTE R FI]YAIYCIAL POLrcY PAPERWORK POLICY Please note that insurance companies will not reimburse us for completing paperwork. We reserve the right to charge for the completion of forms, and other types of paperwork. The processing charge for these forms will start at $25 and will not exceed $200 per futident and will depend on the paper work required. Medical records will be charged at the rate of $ 1 for the first 25 pages and every page after that .25 cents for each additional page SELF PAY POLICY Patient is to pay for services in full and will get a discount if payment is made at the time of the visit. We are contracted with several lnsurance carriers and we Copayments and deductibles are due at the time of service. will bill the insurance company for you. MEDICARE PATIENTS We do file Medicare electronically and as a courtesy we All Medicare deductibles company denials. will file your secondary insurance to Medicare. are due and payable at the time service is rendered. We do not research insurance AUTO ACCIDENTS We will file your auto insurance for you. We will not file with a third party auto insuralce or with an attomey. Our Billing & Insurance Departments needs the following information to perform a successful filing: Name and billing address of the auto insurance, claim adjustei's name and phone number, and the claim number. If there is a denial of your claims you will be held responsible for payment. PATENT NO.SHOW POLICY Advance 24 hours notice is expected if you are not able to keep an appointment. you will be charged a $25 fee for missed appointments. We understand that, on occasion .*..glrr.y situations may occur that prevent a 24-hour notice. These cases will be handled on an individual basis by our Insurance & Billing Department. {<"k****{<{<*'r**r<*d<*t***rFd<*t{<****r<{<rF*****{<{<****{<**{<****{<{<>F{<*>r*{.d<rFx<****{<t Clermont Medical Center's Policy. Signature C07535 Page 2 ol 2 (12/13) rF***tr<*{<rF***xr<**** Patient, Guardian, or Parent) am aware Print of