Signature on file, assignment of benefits, financial agreement
- MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Lansing Ophthalmology for
services furnished me by Lansing Ophthalmology. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT
ME TO RELEASE TO THE Health Care Financing Administration and its agents any information needed to determine these
benefits or the release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the
HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or
agency shown. Lansing Ophthalmology accepts the charge determination of the Medicare carrier as the full charge, and I am
responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge
determination of the Medicare carrier.
- MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or
elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I
request that payment of authorized secondary insurance benefits be made on my behalf to Lansing Ophthalmology, if possible, or
otherwise to me.
- RELEASE OF INFORMATION: Lansing Ophthalmology may disclose all or any part of my medical record and/or
financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any
person or corporation (1) which is or may be liable or under contract to Lansing Ophthalmology for reimbursement for services
rendered, and (2) any health care provider for continued patient care. Lansing Ophthalmology may also disclose, on an anonymous
basis, any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical
education, medical research, for the collection of statistical data or pursuant to Sate or Federal law, status, or regulation.
- OTHER INSURANCE: I understand that Lansing Ophthalmology maintains a list of health care service plans with which it
contracts. A list of such plans is available from the business office and I understand that Lansing Ophthalmology has no contract, expressed or
implied, with any plan that does not appear on the list. The undersigned agrees that I, as an individual, am obligated to pay the full charges
of all services rendered to me by Lansing Ophthalmology if I belong to a plan that does not appear on the above mentioned list.
- NON-COVERED SERVICES: I understand that Lansing Ophthalmology contracts with health care service plans (i.e.,
HMOs, PPOs) that specify items and services which are â€ścoveredâ€ť by the health care service plans. Accordingly, the undersigned accepts
full financial responsibility for all items or services which are determined by the health care service plans not to be covered.
Examples of non-covered services include, but are not limited to, services not specified as being covered in the patientâ€™s contract with
a health care service plan or in the benefit summary the health care service plan furnishes to the patient; and treatment or tests not
authorized by the health care service plan. The undersigned agrees to cooperate with Lansing Ophthalmology to obtain necessary
health care service plan authorizations.
- FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Lansing Ophthalmology, I
will pay my account at the time service is rendered or will make financial arrangements satisfactory to Lansing Ophthalmology for
payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorneyâ€™s fees as
established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be
charged a service fee. Any benefits of any type under any policy of insurance insuring the patient or any other party liable to the
patient is hereby assigned to Lansing Ophthalmology. If co-payments and/or deductibles are designated by my insurance company or
health plan, I agree to pay them to Lansing Ophthalmology. However, it is understood that the undersigned and/or the patient are
primarily responsible for the payment of my bill.
- DIVORCED PARENTS: We do not second party bill. The parent bringing the child to our facility will be
responsible for required co-payments, deductibles etc. at the time of service.
- PRIVACY PLAN: I agree that I have been given the opportunity to read and receive a copy of the Lansing Ophthalmology
Notice of Privacy Practices (Updated as of August 5, 2013).
- NO SHOW FEE: I understand that Lansing Ophthalmology may charge a $50.00 no show fee for any appointments not
canceled within 24 hours.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.