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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.
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Clermont Medical Center's Policy.
Signature
C07535 Page 2 ol 2 (12/13)
rF***tr<*{<rF***xr<****
Patient, Guardian, or Parent) am aware
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