LECANTO SURGERY CENTER



You will be provided the following statement upon arrival at the facility:

LECANTO SURGERY CENTER

P.O. Box 1420 Lecanto, FL 34461

352-527-0102

STATEMENT OF FINANCIAL RESPONSIBILITY

Patient Responsibility: I am are responsible for all charges resulting from services provided by LECANTO SURGERY CENTER. We bill most insurance carriers directly. However, primary responsibility for the account is yours. Payment is due at the time of service, unless other financial arrangements are made. This includes deductibles, copays, and/or co-insurance. If you are an established patient with a delinquent balance you will be asked for payment at the time of service.

Insurance Billing: As a courtesy, we will bill your primary insurance carrier. It is essential that you providing correct insurance information. If your insurance changes, please present your new insurance information as soon as possible or at your next visit. Charges owed due to errors, claim rejections, and/or non-response by the insurance company is the responsibility of the patient. Any procedure and/or supply for procedure(s) provided by LECANTO SURGERY CENTER that is not covered by insurance is the responsibility of the patient. Your health plan may refuse payment of a claim for some of the following reasons: 1) This is a pre-existing illness that is not covered by your plan, 2) You have not met your full calendar year deductible, 3) The type of medical service required is not covered by your plan, 4) The health plan was not in effect at the time of service.

Please understand that financial responsibility for medical services is between you and your health company. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility, as the patient, to pay the denied amounts in full. If, by mistake, your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time. Until we receive any payments made on your behalf, you remain responsible. Verification of eligibility and coverage placed on your behalf to your insurance company IS NOT a guarantee of payment. If your insurance requires a referral and/or authorization from your primary care provider (PCP) to receive treatment at an Ambulatory Surgery Center, it is your responsibility to obtain this authorization.

I understand verification of coverage is not a guarantee of payment. I understand not all BCBS, Tricare, Private Insurance are considered “In-Network” therefore, if coverage cannot be determined prior to my procedure I am responsible for ALL services provided by LECANTO SURGERY CENTER at the usual and customary charge.

Authorization for Release of Information: I authorize LECANTO SURGERY CENTER to release medical information concerning the procedure(s) performed at the Center as may be requested by third party payers in order to process payment of claims.

Charges: The ESTIMATE FACILITY FEE(s) for your procedure(s) today is $_________________________________________.

This is only an estimate and may vary after the procedure is completed and coded by the billing department. Please remember that the physician services are separate from the facility’s fee, and responsibility for payment of the physician’s services is between you and your physician. As applicable, additional services may be provided by other health care providers (anesthesia providers, durable medical equipment and/or anatomical pathologist) who will separately bill and who may or may not participate with the same health insurers or health maintenance organizations as the facility. Insurance information will be forwarded if such services are provided.

I ____________________________________________________________ assign LECANTO SURGERY CENTER all payments to which I am entitled for medical expenses related to the services provided by LECANTO SURGERY CENTER. I understand that I am financially responsible for all charges whether covered by the insurance or not. I also understand if my insurance company has not paid after 60 days, I will receive a statement asking for me to contact my insurance company. If more than 90 days and my insurance company has not sent payment, I will be responsible for the balance. Payment is expected within 10 days of receipt of the statement. I also understand in the event that any such amount is owed and unpaid; the account will be placed with our collection agency.

I HAVE READ and FULLY UNDERSTAND THE TERMS OF THIS POLICY AGREEMENT.

X _____________________________________________ __________________________________________

Patient’s Signature / Signature of Insured Date

X _____________________________________________ __________________________________________

Witness Signature Date

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