Form-Treatment_Authorization

FINANCIAL AGREEMENT

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is NOT A SUBSTITUTE FOR PAYMENT. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance.

IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.

If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney's fees and cost of collection.

I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.

IN CASE OF EMERGENCY,	Name: ___________________________________
WHO SHOULD WE CONTACT:	Address: _________________________________
(Friend or relative not living with you)	City: ___________________St/Zip: ____________
	Phone # _________________________________
	Relationship: ______________________________

INSURANCE ASSIGNMENT OF BENEFITS

• AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Dr. Scott L. Smith's office to release any information acquired in the course of my medical examination and treatment to my insurance carriers as necessary to process my insurance claim.

• AUTHORIZATION TO PAY BENEFITS/TREATMENT:
I here by authorize my insurance carrier to make payment directly to Dr. Smith for the surgical and /or medical benefits payable for the services rendered. I here by authorize treatment for medical services

_______________________________________ PATIENT SIGNATURE (Parent or Guardian of Minor) _______________________________________ DATE	_______________________________________ INSURED'S SIGNATURE

FINANCIAL AGREEMENT Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is NOT A SUBSTITUTE FOR PAYMENT. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT. If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney's fees and cost of collection. I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.

_______________________________________ PATIENT SIGNATURE (Parent or Guardian of Minor) _______________________________________ DATE	_______________________________________ GUARANTOR'S SIGNATURE