Download Patient Information and Insurance Form

PATIENT INFORMATION AND INSURANCE FORM
PLEASE SEE REVERSE SIDE
FINANCIAL POLICY & RELEASE OF INFORMATION TO INSURANCE COMPANIES
Thank you for choosing us as your health care provider for radiology services. We are committed to providing you with high quality
state-of-the-art services. The following is a statement of our Financial Policy which we require you to read and sign prior to any
tests/services.
All patients must complete our Information and Insurance form before any tests will be performed.
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FULL PAYMENT IS DUE AT TIME OF SERVICE UNLESS YOUR INSURANCE PLAN REIMBURSES AT 100% OR WE HAVE A
CONTRACT WITH YOUR PLAN FOR COVERED SERVICES.
WE ACCEPT CASH, CHECKS, POST-DATED CHECKS OR VISA/MATERCARD.
WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR APPROVAL AND DOWN PAYMENT.
WE DO NOT PARTICAPATE IN ANY THIRD PARTY BILLING.
Regarding Insurance:
If we do not have a specific contract with your plan we may accept assignment of insurance benefits depending on your
policy. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance unless you
give us your current insurance information including a billing address. Your insurance policy is a contract between you and your
insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days,
the balance will be billed to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services
and not considered reasonable and necessary under the Medicare Program and/or other medical insurance.
Usual and Customary Rates:
Our practice is committed to providing the best service for our patients and we charge what is usual and customary for our
area. You are responsible for payment regardless of and insurance company’s arbitrary determination of usual customary rates
unless we have a specific contract with your insurance company for specific rates.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
AUTHORIZATION
I accept the responsibility for the charges incurred for the medical services. I authorize Templeton Imaging, Inc. to release any
information contained in my records to my insurance company(s) and/or to any employer (if Worker’s Compensation applies). It is
agreed that payment will not be delayed because of any pending insurance coverage or claims.
Assignment of Benefits:
I hereby assign my insurance and/or Medicare benefits to be paid directly to Templeton Imaging, Inc.
Responsibility and Payments:
I hereby agree to be responsible for payment of any procedure not authorized or deemed necessary by my insurance company, or
MediCal. I agree to be responsible for payment in full. If my insurance, or MediCal denies payment for any exams performed on me
by Templeton Imaging, Inc.
I have Read, Understood, and Agreed to all the above statements on this form.
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Signature of patient or responsible party
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Date