Form: New Patient Information

Thank you for choosing us as your healthcare provider. We are committed to providing you with the highest quality of care. The following is a statement of our financial policy, which we require you read and agree to sign prior to any treatment.

Patient Financial Responsibilities

• It is my responsibility to know my own insurance benefits, including whether AzOPT is a contracted provider with my insurance company, my covered benefits, and any exclusions in my insurance policy, and any pre-authorization requirements of my insurance company.
• AzOPT will attempt to confirm my insurance coverage prior to my treatment. It is my responsibility to provide current and accurate insurance information, including any updates or changes in coverage. I am financially responsible should I not provide this information.
• Estimate charges may be given at or before the time of service, but I understand that this is merely an estimate, based on information available at this time. Actual amount I will be charged for services rendered may be different from the estimate of charges for a variety of reasons, including but not limited to, additional treatments, supplies, or services not covered in the estimate.
• AzOPT will bill my insurance company first, less any copayment(s) or deductible(s), and then bill me for any amount determined to be my responsibility, in accordance with my insurance policy. This process generally takes 45-60 days from the time the claim is received by the insurance company. A detailed Explanation of Benefits (EOB) is available from the insurance company when the claim is finalized.
• If my insurance contract contains a Coordination of Benefits (COB) provision, it is my responsibility to contact my insurance plan and update the necessary information. I am aware that if this is not done, I am responsible for any visits not paid by insurance.
• If I am uninsured, I agree to pay for the services rendered to me at the time of service. If I am unable to pay the totality of the medical services rendered at the time of service, I will make a payment plan or other payment arrangement with the clinic.
• Co-pays and/or deductible payments are due at the time of service.
• AzOPT will ask to make a copy of my ID and insurance cards for their records.
• AzOPT accepts any form of payment – cash, check, or credit card.
• In the event that a payment is missed, accounts need to be settled prior to the next appointment, or future scheduled appointments may be cancelled.

Patient or Guarantor

I have read and understand the above. I understand I will be responsible for payment of any amounts not covered by my insurance carrier, including, but not limited to, co-payments and deductibles.