Authorization and Financial Understanding
By accepting the medical services provided to me by Lane L. Smothers, MD and/or any other employee of corporation, I agree to be financially responsible for the charges billed by Casper General Surgery.
If there is a medical insurance which will cover all or a portion of the charges I incur, by Lane L. Smothers or any other employee of the corporation for my treatment, I hereby assign those insurance benefits to Casper General Surgery and authorize the insurance benefits to be paid directly to Casper General surgery. This assignment will remain in effect until revoked by me in writing.
I understand and agree that if my insurance benefits do not cover all of the charges for my treatment, including what my insurance company classifies as over reasonable and customary charges, that i am responsible to pay any outstanding balances. I further agree that in the event of a non-payment to Casper Genera Surgery, of any amounts due under this agreement I will pay interest thereon at the rate of 1.75% per month and pay all of Casper General Surgery reasonable legal fees, attorney fees and court costs that may be incurred. I agree that in the event that this agreement is assigned to a collection agency for collection, I promise to pay a collection fee of 35% of the unpaid balance due which is in addition to the unpaid balance due under this agreement.
I understand that it may be necessary for Casper General Surgery to disclose medical information about my treatment to my insurance companies, employer, or third-party payers in order to process a claim on my behalf.
A photocopy of this assignment and financial agreement is considered to be as valid as an original.
I understand that it is my responsibility to contact my insurance company for pre-authorization procedures.