Financial Responsibility Form



ACCEPTANCE OF FINANCIAL RESPONSIBILITY: I understand that I am responsible for all medical expenses regardless of insurance coverage and whether or not there is an accident with another person at fault.

COLLECTION COSTS: I hereby agree that should my account balance become delinquent more than 60 days that I will pay for all costs incurred by Chesapeake Bay E.N.T. (CBENT) for the collection of my delinquent account including but not limited to legal fees, court costs and collection agency costs.

AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION: I have read and fully understand CBENT's Notice of Patient Information Practices. I acknowledge receipt of a copy of the policy. I understand that CBENT may use or disclose my personal health information for the purposes of carrying our treatment, obtaining payment and evaluating the quality of services provided. I understand that I have the right to request restrictions of how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice in writing. I also understand that the practice will consider the request for restriction on a case-by-case basis, but does not have to agree to requests for restrictions. I understand that other physicians involved in my care, including my referring physician and primary care physician will be kept informed of my treatment.

I hereby consent to the use of my personal health information for the purposes as noted in the Notice of Patient Information Practices. I understand that I have the right to revoke this authorization in writing, at any time by sending such written notification to the Office Administrator at the address listed.

ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to Chesapeake Bay E.N.T. of the medical and/or surgical benefits of my insurance plan(s).

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