Insurance & Financial Policy — Primary Health Clinics of Mississippi

Primary Insurance

Insurance Company Name

Plan / Group Name

Member ID / Policy Number

Group Number

Subscriber Name (if different from patient)

Subscriber Date of Birth

Subscriber Relationship to Patient

Self

Spouse

Parent

Other

Insurance Phone Number (on back of card)

Copay Amount

Effective Date

Secondary Insurance (if applicable)

Insurance Company Name

Plan / Group Name

Member ID / Policy Number

Group Number

Subscriber Name (if different from patient)

Subscriber Relationship to Patient

Self

Spouse

Parent

Other

Financial Policy

Please read the following financial policy carefully before signing.

Insurance Billing. Primary Health Clinics of Mississippi will bill your insurance carrier as a courtesy. You are responsible for providing accurate and current insurance information at each visit. If your insurance changes, please notify us before your appointment. We are not responsible for denied claims resulting from inaccurate information provided by the patient.

Co-pays, Deductibles & Co-insurance. Co-pays are due at the time of service. Deductibles and co-insurance amounts are your responsibility and are due upon receipt of your Explanation of Benefits (EOB) from your insurer. We accept cash, check, and major credit/debit cards.

Self-Pay Patients. Payment in full is due at the time of service. Please call our office at (601) 357-5118 to inquire about self-pay rates before your visit.

Referrals & Prior Authorizations. Some insurance plans require a referral or prior authorization before certain services are rendered. It is the patient's responsibility to obtain required referrals. Services rendered without required authorization may result in the patient being responsible for the full charge.

Unpaid Balances. Balances not paid within 90 days of the statement date may be referred to a collection agency. A $25 returned check fee will be assessed for any returned checks.

Missed Appointments. We request at least 24 hours' notice for appointment cancellations. Repeated no-shows or late cancellations may result in a fee or discharge from the practice.

Medicare & Medicaid. PHCM participates in Medicare and Medicaid. Patients covered by these programs are subject to all applicable federal and state regulations regarding billing and payment.

Assignment of Benefits & Authorization

I hereby authorize Primary Health Clinics of Mississippi to release any information necessary to process my insurance claims, and I assign all insurance benefits payable to me to PHCM for services rendered. I understand that I am financially responsible for all charges not covered by my insurance. I authorize PHCM to contact me by phone, text, or email regarding my account balance and appointment reminders.

Patient Signature (or Legal Representative)

Date

Printed Name

Relationship to Patient (if not self)

Credit Card Authorization (Optional)

You may authorize PHCM to keep a credit card on file for co-pays, balances, and other patient responsibility amounts. This is optional and not required for treatment.

Cardholder Name

Card Type

Visa

MC

Amex

Disc

Card Number

Expiration Date

CVV

Billing ZIP Code

Cardholder Signature

Date

By signing above, I authorize PHCM to charge the card on file for patient responsibility amounts. I may revoke this authorization at any time in writing.