West Florida Internal Medicine W Street
West Florida Primary Care Nine Mile Road Immediate Care Pediatrics
Pace
Pine Forest Spanish Trail West Pensacola
W Street Avalon
PATIENT FINANCIAL AGREEMENT
West Florida Specialty Physicians General Surgery CV Surgery
Cardiology
Orthopedic Surgery Obstetrics/Gynecology Neurology
West Florida Behavioral Health West Florida Internal Medicine
1. ____________(Patient or Guardian Initials)
Financial Agreement.
I acknowledge, that as a courtesy, WEST FLORIDA MEDICAL GROUP may bill my insurance company for services provided to me. I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance. I understand that there is a fee for returned checks.
2. ___________(Patient or Guardian Initials)
Third Party Collection. I acknowledge that WEST FLORIDA MEDICAL GROUP may utilize the services of a third party
business associate or affiliated entity as an extended business office ("EBO Servicer") for medical account billing and servicing.
3. ___________(Patient or Guardian Initials)
Assignment of Benefits. I hereby assign to WEST FLORIDA MEDICAL GROUP any insurance or other third-party
benefits available for health care services provided to me. I understand WEST FLORIDA MEDICAL GROUP has the
right to refuse or accept assignment of such benefits. If these benefits are not assigned to WEST FLORIDA MEDICAL
GROUP, I agree to forward all health insurance or third-party payments that I receive for services rendered to me
immediately upon receipt.
4. ______________(Patient or Guardian Initials)
Medicare Patient Certification and Assignment of Benefit. I certify that any information I provide, if any, in applying
for payment under Title XVIII ("Medicare") or Title XIX ("Medicaid") of the Social Security Act is correct. I request
payment of authorized benefits to be made on my behalf to WEST FLORIDA MEDICAL GROUP by the Medicare or
Medicaid program.
5. ______________(Patient or Guardian Initials)
Consent to Telephone Calls for Financial Communications. I agree that, in order for WEST FLORIDA MEDICAL
GROUP, or EBO Servicers and collection agents, to service my account or to collect any amounts I may owe, I
expressly agree and consent that WEST FLORIDA MEDICAL GROUP or EBO Servicer and collection agents may
contact me by telephone at any telephone number, without limitation of wireless, I have provided or WEST FLORIDA
MEDICAL GROUP or EBO Servicer and collection agents have obtained or, at any phone number forwarded or
transferred from that number, regarding the services rendered, or my related financial obligations. Methods of
contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as
applicable.
6. ______________(Patient or Guardian Initials) A photocopy of this consent shall be considered as valid as the original.
Patient/Patient Representative Signature:
X________________________________________________________________________Date_________________
If you are not the Patient, please identify your Relationship to the Patient.
(Circle or mark relationship(s) from list below):
Spouse Parent
Legal Guardian
Guarantor
Healthcare Power of Attorney
Other (please specify)_______________________________
8383 North Davis Highway ? Pensacola, Fl 32514 ? (850) 494-4600
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