Patient Responsibility Form
- INDIVIDUAL'S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance
deductible, coinsurance or non-covered service.
- Co-payments are due at time of service.
- If my plan requires a referral, I must obtain it prior to my visit
- In the event that my health plan determines a service or hearing device not
be a covered benefit, I will be responsible for the complete charge and
agree to pay the costs of all services provided.
- If I am uninsured, I agree to pay for the medical services rendered to me at
Ultimately, it is the patient's responsibility to verify their insurance benefit.
To save time, please be sure to call your insurance company before your
INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to Diablo Hearing
Services, Inc. on my behalf for any services furnished to me by the providers.
- AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Diablo Hearing Services, Inc. to release to my insurer,
governmental agencies, or any other entity financially responsible for my
medical care, all information, including diagnosis and the records of any
treatment or examination rendered to me needed to substantiate payment for such
medical services as well as information required for precertification,
authorization or referral to other medical provider.
- MEDICARE REQUEST FOR PAYMENT
I request payment of authorized Medicare benefits to me or on my behalf for any
services furnished me by or in Diablo Hearing Services, Inc. I authorize any
holder of medical or other information about me to release to Medicare and its
agents any information needed to determine these benefits or benefits for