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1、OFFICE PAYMENT POLICIESWelcome to Northwestern Medical Imaging, LLC.(NWMI). Our professional staff is committed to your health and welfare. Following is a statement of our office payment policies.AUTHORIZATIONI hereby authorize the release of pertinent medical information to my insurance carriers, a
2、nd I agree to the assignment of benefits to NWMI. I am aware that health insurance coverage varies, and while insurance carriers may use such terms as “customary,” “reasonable”, “prevailing,” etc., to limit their coverage, I am ultimately responsible for the payment of all charges for services rende
3、red at NWMI. I will be responsible for all co-payments, deductibles, co-insurance and charges for services that are not considered medically necessary by my insurance company but have been rendered by NWMI at the direction of my physician for my care and well-being.PRECERTIFICATION OF PROCEDURESAs a
4、 courtesy to our patients we will verify your insurance benefits and precertify the exam you are having at our facility. Precertification is not a guarantee of payment by the insurance company.RETURNED CHECKSI understand that if the bank returns my check paid for services rendered by NWMI, then NWMI
5、 will apply a $50.00 processing fee. This fee will be added to my account, and I will be responsible for the payment of this fee.ATTORNEY FEESIn the event I fail to pay the balance of my account with NWMI within ninety(90) days from the date of service, my account will be turned over for collection
6、unless prior payment arrangements have been made. It will be my sole responsibility to see that my bill has been handled and payments made to this office. In the event NWMI turns over my account for collection pursuant to this policy, I will be responsible for the payment of the account balance plus
7、 additional charges for the costs of collection, including attorney fees, attorney charges and interest charges assessed in accordance with law.NORTHWESTERN MEDICAL IMAGING, LLC.OFFICE AND PAYMENT POLICIESAcknowledgement and ReleaseI have read and fully understand the Office Payment Policies. I have
8、 been given a copy of this document. I understand that these Policies and the authorizations I have given in this document shall apply to all services rendered to me, my dependents, and any other person for whom I have assumed financial responsibility by signing below from this date forward until I have revoked such authorization in writing._Signature of Patient(Insured or Legal Guardian)DatePrinted Name of SignerPatients Printed Name
