SECONDARY INSURANCE. Having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Secondary insurers have specific guidelines, stated in your contract with them, for what they will consider for payment in coordination with your primary insurance payment. We bill your primary and secondary insurance carrier as a courtesy. You are responsible for any balances after your insurance(s) has cleared. If the subsequent insurance carrier doesn’t pay after 45 days, we may turn the balance due to your responsibility. Subsequent insurance billing may be subject to a billing fee of $5.00 per claim.
SECONDARY INSURANCE. As a courtesy, we will bill your secondary insurance as long as you provide us with the correct and current information. You are ultimately responsible for any deductibles, co- pays, co-insurances, or non-covered services your contract requires.
SECONDARY INSURANCE. Insurance Company Insured Member Relationship to Insured Member (Circle one) Self Spouse Child Other: Plan/Group #
SECONDARY INSURANCE. Do you have a second insurance that covers health care? ❒ Yes ❒ No Are your services to be paid by Worker’s Comp or Auto Accident Insurance? ❒ Yes ❒ No Are you using an EAP Employee Assistance Program to pay for services: ❒ Yes ❒ No If YES to any of the above, request and complete additional insurance information form.
SECONDARY INSURANCE. I understand that my secondary claim is billed as a courtesy only and will be submitted to the appropriate party ONE TIME. After that one-time submission, if the insurance company does not pay within 60 days or denies the claim, I (the patient) will be financially responsible to pay.
SECONDARY INSURANCE. Insurance Company: Policy Xxxxxx’s Name and Employer: Relationship to Policy Holder (PH): ( ) Self ( ) Other - DOB of PH: Patient SSN: Phone Number: Patient Address: Is your condition due to a MOTOR VEHICLE ACCIDENT? If YES, are you going through your auto insurance? If you are going through your personal health insurance, please notify front office staff before being seen. Patient Name: Signature of Patient or Guardian: Patient Name: DOB: Patient Address: Email Address: ❑ Y ❑ N May we reach out to you by email? Primary Phone: ❑ Y ❑ N May we leave confidential voicemail?
SECONDARY INSURANCE. Patients who are covered by more than one medical insurance carrier should notify the Practice at the time of registration. It is your responsibility to know the limitations of your supplemental/secondary policy. If you have two insurance policies, the co-payment of the primary insurance is collected at the time of service.
SECONDARY INSURANCE. Patient’s
SECONDARY INSURANCE. The Organization provides supplemental medical insurance for each Minor Participant at no additional cost. This secondary insurance may pay for expenses related to injuries or emergency illnesses incurred by the Participant, while at camp or traveling to/from camp, that are in excess of your personal health insurance. Policy exclusions and coverage limits apply. Expenses must be submitted to the Undersigned Person’s primary health insurance carrier first, then filed with the Organization’s supplemental insurance provider (a $25 deductible applies). Claim forms and contact information will be provided as needed.
SECONDARY INSURANCE. The Texas Department of Insurance requires the patient to provide secondary insurance coverage to the provider if applicable. Patient agrees to provide such information as outlined below. Patient agrees to notify provider in the future immediately of any additions changes or deletions in primary or secondary insurance coverage.
