NOTE: If your insurance requires a referral, it is your responsibility, as the patient, to obtain this authorization and make sure it is available to our office the day of your appointment. Your insurance carrie may not cover expenses occurred without this authorization. If no valid referral is on file, your appointment will be rescheduled.
ASSIGNMENT & RELEASE: I hereby assign my insurance benefits to be paid directly to West TN Neurology. I am financially responsible for non-covered services. I also authorize the physician to release any information required to process this claim. I understand that I am responsible for paying my bill in full after 90 days, if my insurance has failed to do so.
I hereby give my consent for West TN Neurology Clinic, PLLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). West TN Neurology Clinic, PLLC notice of privacy practices provides a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. West TN Neurology Clinic, PLLC reserves the right to revise its notice of privacy practices at any time. A revised Notice of Privacy practices may be obtained by forwarding a written request to West TN Neurology Clinic, PLLC privacy officer at 6570 stage Road, Suite 202 Bartlett, TN 38134.
With this consent, West TN Neurology Clinic, PLLC may call my phone or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others
With this consent, West TN Neurology Clinic, PLLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards in patient statements as long as they are marked personal or confidential.
With this concern, West TN Neurology Clinic, PLLC may email to my home or other alternative location any items that assist the practice in carrying out TPO such as appointment reminders and patient statements. I have the right to request that West TN Neurology Clinic, PLLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to West TN Neurology Clinic, PLLC use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent, or later revoke it, West TN Neurology Clinic, PLLC may decine to provide treatment to me.
At West TN Neurology Clinic, PLLC we strive to give you the best possible care. In order to serve this purpose, it is important you understand the process of reimbursement. Please read this financial responsibility form and sign at the bottom to acknowledge you understand your accountability
It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations, as well as authorization requirements. This information can be obtained by contacting your insurance carrier. It is also your responsibility to know if our providers are in or out of network with your particular insurance carrier. If you do not have coverage within your network, you will be responsible for payment in full.
Copayments and coinsurances are your responsibility. Your insurance company expects us to collect from you at the time of service.
You are responsible for your deductible. Deductible is determined by your individual contract with your insurance carrier. We may not have full detailed information about your deductible amount or how much of that has been met. You are responsible for finding out all your deductible information prior to appointment at our office.
All patients are responsible for payment if their insurance denies payment for any services rendered because they were stated as “non-covered services” or deemed as “medically unnecessary“. To avoid this please check with your insurance carrier prior to receiving any treatment. Obtain required authorizations or referrals before your visit is scheduled.
All cash patients and patients without valid insurance information are considered a self pay patient. A self pay patient is required to pay for the office visit and any testing on the day service is to be rendered to the front desk personnel. Should you have insurance, but are unable to provide information, at the time of your visit you are expected to pay at the time of service until your insurance information is on file.
Please note patients will be charged $50.00 for missed appointments, not canceled within 24 hours of the scheduled time.
