I hereby authorize Maryland ENT Associates to apply for benefits on my behalf for services rendered to my minor child and request that payment be made by my insurance company and that payments be sent directly to Maryland ENT Associates. I understand that it is the policy of Maryland ENT Associates to only bill my insurance company if they participate with that company, and if they do not, it will be my responsibility to bill my insurance company for reimbursement of my expenses. I further authorize Maryland ENT Associates to release necessary information to my insurance company, or to the Insurance Commissioner of MD as necessary to obtain payment for my services.
I understand that this in no way relieves me of my primary responsibility to pay for services rendered to my minor child, and if my account is turned over to an attorney for collection, I agree to pay any collection and reasonable legal fees (40% is deemed reasonable) court costs, and other expenses incurred as a result of said collection, all actions having a venue of Montgomery County, MD, other venues notwithstanding. Further, I understand that there is a $25.00 fee for returned checks and $50.00 for missed appointments.
I certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing.
I understand that the information contained on this form will be used to process my billing and/or insurance claims for service received in this office. It is important to be sure that this information is correct prior to receiving care to prevent problems for the patient in the future.
Click here to view our Notice of Privacy Practices.
I have received the Notice of Privacy Practices from Maryland ENT Associates, effective date 9/23/2013