NOTE: AS A COURTESY, WE WILL BILL YOUR INSURANCE FOR YOU AFTER YOUR DEDUCTIBLE HAS BEEN MET.Treatment and Financial Agreement • September 2nd, 2014
TREATMENT AND FINANCIAL AGREEMENT: PAYMENT IS DUE AT THE TIME OF SERVICE. AN OFFICE VISIT CHARGE MAY BE MADE IF AN APPOINTMENT IS NOT CANCELED IN A TIMELY FASHION. INDERSIGNED AGREES AND REQUEST THAT ALL PAYMENTSMADE BY INSURANCE BE SENT DIRECTLY TO PROVIDER WITH INSURED AND PROVIDER AS JOINT PAYEES. AUTHORIZATION IS HEREBY GIVEN TO RELEASE COPIES OF MEDICAL RECORDS TO CARRIER IF REQUESTED FOR CLAIM PROCESSING. IN CONSIDERATION FOR MEDICAL SERVICES RENDERED BY DR. RAO. THE UNDERSIGNED AGREES THAT REGADLESS OF INSUANCE STATUS, UNLESS THERE IS A CONTRACTUAL AGREEMENT TO THE CONTRATY (AS IN THE DASE OF MEDICARE OR A PPO), OR IN THE EVENT THAT INSURANCE COVERAGE IS DENIED, THAT HE OR SHE IS PERSONALLY RESPONSIBLE FOR THE PROMPT PAYMENT OF CHARGES FOR ALL MEDICAL SERVICES RENDERED. IT IS FURTHER AGREE THAT ALL DELINQUENT ACCOUNTS, THAT THE COURT SHALL AWARD TO THE PROVIDER PREJUDGEMENT AND POST-JUDGEMENT INTREST, COURT COST AND REASONABLE ATTORNEY FEES, AND THAT UNDERSIGNED SHALL PAY THE FE
Treatment and Financial AgreementTreatment and Financial Agreement • February 16th, 2023
Treatment: HUPTI accepts the patient named below for proton therapy treatment. The undersigned hereby consents to HUPTI providing and administering all services and supplies ordered by the patient’s attending physicians, and to the performance of all proton therapy procedures they deem advisable. I acknowledge that all medical treatment involves some risks and that no guarantee can be given regarding the outcome.
