By signing this document, I am agreeing to the terms of this policy.

PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate. You will be charged a $25 service fee for any returned checks, no exceptions.

INSURANCE: I certify that the information given by me in applying for Insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my Insurance and/or Medicare benefits, and I authorize payment of these benefits to Dr. Nash on my behalf for any services and materials furnished.

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 payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of agency shown, and authorizes my doctor to act as my agent, as above.

Patients will be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. Claims not paid within 60 days by your insurance company will become your responsibility. You will receive a statement for these services, and you will need to contact your insurance company for reimbursement.

For those patients covered by insurance plans with which we ARE participating providers, all co-payments, deductibles and noncovered services are due at time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy. Any charges that are not paid by your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.

COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 90 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.

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