Patient Financial Responsibility Contract

Patient Name

-Payment in full is due at the time of service.

Please read, initial each blank and sign where indicated - this document describes your financial responsibility as a patient with Sayana Medical & Wellness Center.

This is a legally binding contract between Sayana Medical & Wellness Center and you. The words, I, me, my, you, and your all refer to the patient.

I agree to be financially responsible for payments on balance due to Sayana Medical & Wellness Center services. Cash or credit cards are acceptable forms of payment for those services.

Current insurance cards must be presented at every office visit. Sayana Medical & Wellness Center is not responsible for filing your insurance claim, but as a courtesy we will do so. I agree to pay the remaining balance after my insurance has paid on my claim immediately upon receipt of a statement.

I agree to give Sayana Medical & Wellness Center my complete and accurate insurance information for primary and secondary insurance benefits including referral documents from other providers, if needed. I understand that if I fail to give complete and accurate information about my insurance benefits, this may result in a denial of my claim or a delay in payment. I agree to pay Sayana Medical & Wellness Center the balance on my account after my insurance claim has been processed.

I understand that I will be responsible for any missed appointments or any canceled appointments in which a 48 hour (business hours) notice was not given. There will be a fee of $50.00 for any missed office visits.

I understand that my benefits may not cover all services or might deny payment for services that have been ordered by Sayana Medical. I agree to pay the balance remaining on my account after insurance has been processed.

If I have a high deductible policy or do not currently have insurance benefits, I agree to pay an estimate of charges for my office visit in advance and understand that other charges may apply.

Sayana Medical & Wellness Center has a contract with my insurance company. Sayana Medical & Wellness center will receive payments from my insurance company for covered services provided by my insurance benefits. I agree to pay co-payments and deductibles at the same time of service. If co-payments and deductibles are not made at the time of service, I understand that my appointment may be no-showed.

I agree to pay any balance remaining on my account for any reason upon receipt of a statement and I understand that when requested, I must give Sayana Medical & Wellness Center my current address and other contact information. I understand that if I fail to pay the balance on my account this may result in termination as a patient at Sayana Medical and wellness center.

I have read and I understand Sayana Medical & Wellness Center financial policies and I accept responsibility for the payment of any fees associated with my care.

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Assignment of Benefits

I hereby authorize direct payment of medical benefits, including medical benefits to which I am entitled to Sayana Medical & Wellness Center. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS. This authorization will remain in effect until canceled by me in writing. A copy of this authorization is valid as the original document.

I authorize the release of any medical information necessary in order to obtain payment and I understand that I am financially responsible for all charges, late fees, interest , attorney fees and collection charges considered patient responsibility by my insurance company. I understand that if I am not insured, I am responsible for the charges of all services provided to me.

A $5 fee late fee will be assigned for co-pays not paid at the time of service.

I have read and I understand Sayana Medical & Wellness Center financial policies and I accept responsibility for the payment of any fees associated with my care.

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Patient Financial Responsibility Contract will be submitted to Sayana Medical Spa and Wellness Center