FINANCIAL AGREEMENT

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time.  Your clear understanding of our Financial Policy is important to our professional relationship.  Please ask if you have any questions about our fees, financial policy, or financial responsibility.

PATIENTS MUST COMPLETE THE PATIENT REGISTRATION FORMS PRIOR TO SEEING THE DOCTOR.  WE WILL REQUEST TO SCAN YOUR INSURANCE CARD(S) FOR YOUR FILE.

• REFERRALS – If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit.  If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER.  It is then your responsibility to provide us with the referral within 48 hours or you will be personally responsible for that day’s services.
• CO-PAYMENTS – By law we MUST collect your carrier designated co-pay.  This payment is expected at the time of service.  Please be prepared to pay the co-pay at each visit.  Should you not pay at the time of service and we subsequently send you a statement, an administrative fee of $20 may be added to your account.
• OUT-OF-NETWORK-PLANS – You will be responsible for any balance your plan indicates as due on their explanation of benefits form.  We will adjust the charges to coincide with your plan’s UCR (Usual, Customary, and Reasonable) charges.  All patients will be responsible for their co-insurance and deductible.  If we do not “participate” with your plan, we will send a courtesy bill to that carrier on your behalf.  However, should they not pay your claim within 45 days, you will be responsible for the full amount due.  Should you receive payment from your insurance carrier, please forward it to the physician’s office along with a copy of the explanation of benefits.

Private Insurance Authorization for Assignment of Benefits/Information Release:  I, the undersigned, authorize payment of medical benefits to Bergen Ear, Nose and Throat Associates or Brian Benson, M.D. for any services furnished.  I understand that I am financially responsible for any amount not covered by my contract.  I also authorize any holder of medical information about me to release to my insurance company (or their agent) information concerning health care, advice, treatment, or supplies provided to me.  This information will be used for the purpose of evaluating and administering claims of benefits.

• SELF-PAY PATIENTS – Payment is expected at the time of service unless other financial arrangements have been made prior to your visit.
• MEDICARE – We will submit claims to Medicare.  The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one.

Medicare Lifetime Signature on File:  I request that payment of authorized Medicare benefits be made on behalf to Bergen Ear, Nose, and Throat Associates or Brian Benson, M.D. for any services furnished to me.  I authorize any holder of medical information about me to release to CMS (and its agents) any information to determine these benefits payable for related services.  This information will be used for the purpose of evaluating and administering claims of benefits.

• DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – The parent who consents to the treatment of a minor child is responsible for payment of services rendered.  Bergen Ear, Nose and Throat Associates or Brian Benson, M.D. will not be involved with separation or divorce disputes.
• ALLERGY TREATMENT PATIENTS – If you are an allergy patient who is consenting to receive allergy treatment, it is important that you understand your benefits and responsibilities related to the cost of this type of therapy.  Once you consent to receive allergy treatment, our allergy clinic will verify your insurance coverage and will notify you if there are any large out-of-pocket expenses before preparing the serums and submitting a bill to your insurance company.  If there is a large out-of-pocket amount due, we can discuss a payment plan, or you may decide to decline to receive allergy treatment.

You are responsible for the timely payment of your account.  Should it become necessary for us to use an outside agency to collect payment from you, you will be additionally responsible for the collection fees we incur because of this.

WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, DISCOVER, OR AMERICAN EXPRESS

THANK YOU for taking the time to review our policies.  Please feel free to ask any questions or share with us special concerns.

I hereby agree that you may contact me for whatever reason concerning my account on any and all of the phone numbers I have provided to you, including but not limited to home phone, work phone, cell phone, or any other phone number.