ultimately responsible for your account:
expedite your visit please send us your updated insurance
information so that we can pre-certify your visit.
* Other Insurance:
* Group #: SSN:
Insurance Billing address:
If a required
field does not apply to you put none.
I understand that all charges (including those not paid by
insurance), collection fee, bank/returned check fees, legal
fees and failure to keep appointment fees are the financial
responsibility of the patient (or the parent/guardian in the
case of a minor). I hereby authorize Dr. Schweinshaupt to
release all information concerning my illness (es) and
treatments to my insurance carriers/health plans. In the
event that Dr. Schweinshaupt participates with my insurance
carrier/health plan, I hereby assign all available benefits
and payments directly to him for medical services rendered.
I understand that I am financially responsible for all
balances not covered by my insurance carrier/health plan,
and authorize Dr. Schweinshaupt to charge my credit card for
the full amount of any unpaid balances. I acknowledge
notification of the privacy practice act.
* denotes required field