Patient Financial Obligation Agreement
GHENTMD will submit claims on your behalf to insurance carriers with which we participate. At GHENTMD, we are dedicated to high quality care and go beyond the standard medical care to our patients. Forms of payment accepted include cash, check, major credit cards and payment plans. Comprehensive physicals, certain laboratory tests, procedures, and recommended medications including nutritional supplements may not be covered. When indicated, prior authorizations may be completed at the discretion of our providers. We cannot guarantee that all services and therapies we provide or recommend are covered by your insurance. We strongly encourage you to contact your insurance carrier ahead of time and verify appropriate coverage. It is YOUR RESPONSIBILITY to know your insurance plan benefits. Billing your insurance does not necessarily guarantee payment by the insurance company nor does it release the responsible party from its financial obligation to GHENTMD for any unpaid balance. In case of an insurance partial payment, the balance is due by YOU and we will send you a billing statement. GHENTMD is not responsible to negotiate a settlement for a disputed claim. You understand that all applicable copays and deductibles are due at the time of service. You agree to be financially responsible and make full payment for all charges not covered by your insurance company. You authorize your insurance benefits to be paid directly to GHENTMD for services rendered. You authorize representatives of GHENTMD to release pertinent medical information to your insurance company when requested or to facilitate payment of a claim. Cash or Self-Pay Patients: All payments are to be paid at the time of services. You are a cash or self-pay patient until you submit active insurance cards, and GHENTMD qualifies and accepts your insurance coverage. If your account with GHENTMD is delinquent more than 120 days and no payment arrangement has been established, we may involve a collection agency to recover the full amount owed. A re billing fee of $20 will be charged for all re billing. For accounts placed in collection, a $50 additional charge will be placed. Any check returned for non payment will generate an additional processing fee of $40.