Assignment of Benefits

By signing electronically, you (or as parent/guardian on behalf of a minor) agree that: the information provided is correct; the Practice and providers may release information needed to process claims; the Practice shall be paid or assigned benefits on the patient's behalf; you will cooperate with insurance companies to process claims; you are responsible for costs not covered by benefits including non-covered services, deductibles, and co-insurance. If signing as parent/guardian, you represent you have legal authority to execute this agreement.

You request that any benefits due for treatment from insurance companies or third-party payers be paid or assigned to the Practice. This includes any insurance settlements related to treatment. If the payer will not pay the Practice directly, you will forward any payments received.

You understand insurance may not cover all costs. You are personally responsible for: costs not covered by insurance or that exceed benefit limits (including self-administered medications, certain durable medical equipment, certain medical supplies); services determined to be experimental, investigational, not covered, or not medically necessary but that the patient wishes to receive.

If the patient is a beneficiary of a government health program, neither the patient, provider, nor the Practice will submit claims for reimbursement to any federal or state healthcare program except Medicare Advantage plans. Submission to Medicare Advantage plans is expressly permitted. All other government program claims (Medicare Part B FFS, Medicaid, Tricare, Veterans Affairs) are strictly prohibited.

You understand that: the guarantor (including parent/guardian) is responsible for charges not covered by insurance; charges are due when treatment stops; you may request an estimate of charges; the Practice may bill insurance but may also ask for payment in advance; you are responsible for all charges across all Practice accounts; should the bill go to collection, you will pay resulting costs including attorney fees and collection agency fees.

Your electronic signature constitutes your legal signature under the E-SIGN Act and applicable state laws. You have had the opportunity to read this agreement in full. If signing as parent/guardian, you confirm your authority and agree to provide documentation upon request.