Financial Agreement

Your clear understanding of our Financial Policy is important. Please ask if you have any questions about our fees, financial policy, or your financial responsibility. We do our best to provide you with as much information as we can regarding your financial responsibility for testing and treatment. When using insurance, ultimately, your financial responsibility is due to the agreement between you and your insurance company. PLEASE read through the forms carefully. It is your responsibility to understand what may occur financially with your testing and treatment.

By signing the Electronic Signature Acknowledgment and Consent Form, I confirm that I have read this agreement, understand it, and acknowledge that the electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Sign in to Google to save your progress. Learn more
Please INITIAL below by each item, verifying you have read and understand our financial policies.
APPOINTMENTS/CANCELLATIONS – 48-hour notice must be provided in the event you cannot keep an appointment. Should you not provide this notice a cancellation fee for Case History Calls $40 (added to the cost of your full evaluation), AVT first time $35.00, then $50.00 for the second and thereafter. BPPV, ECochG are charged $100. A Full Eval is $200.00.
 *
REFFERALS – If your plan requires a referral from your PCP, it is YOUR responsibility to obtain it prior to your appointment and have it in our office at the time of your visit. If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER to be set up as a “Self-Pay” patient. It is then your responsibility to provide us with the referral within 48 hours or you will be personally responsible for that day’s services.
 *
CO-PAYMENTS – By law we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit.  Any procedure performed in this office should be deemed medical by your insurance company and all copays and deductibles will apply.
 *
FMLA AND/OR WORKMANS COMP – There is a $50 charge for completion of Workman’s Comp, FMLA, and any other request for forms to be completed by our staff.
 *
DEPOSITS – If our office determines that your course of care requires a deposit to hold an appointment, it will be collected at time of scheduling.
 *
IN/OUT OF NETWORK PLANS – You will be responsible for any balance your plan indicates as due on their explanation of benefits form. We will adjust the charges to coincide with your plan’s UCR (Usual, Customary and Reasonable) charges. All patients will be responsible for their co-insurance and deductible. If we do not “participate” with your plan, you will be responsible for the full amount due. (**Private Insurance authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to MDBI for any services furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any holder of medical information about me to release to my insurance company (or the agent) information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.**)
 *
NO SURPRISES ACT – As a courtesy we do verify your insurance to check in and out of network benefits as well as to determine if our testing and treatment is covered by your insurance. Once we obtain this information, we use a medical software to produce a cost ESTIMATE based on what your insurance has told us. This is just an estimate and is never a guarantee of payment by your insurance. Insurance plans can adjust the rates as well at will and this is out of our control. The Estimate is always provided to you BEFORE your appointment for your review. The estimate is due AT TIME OF SERVICE.
MEDICARE – We submit claims to Medicare. The patient will be responsible for the deductible and 20% co-insurance, which can be billed to a secondary insurance. (**Medicare Lifetime Signature on file: I request that payment of authorized Medicare benefits to be made on my behalf to MDBI for any services furnished to me. I authorize any hold of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This information will be used for the purpose of evaluation and administering claims of benefits.**)
 *
SELF-PAY PATIENTS – Payments is expected at the time of service.
 *
DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – The parent who consents to the treatment of a minor child is responsible for payment of services rendered, Midwest Dizziness and Balance Institute will not be involved with separation or divorced disputes.
 *
INSUFFICIENT FUNDS CHECKS – A $25.00 fee will be charged to patient’s account for checks returned due to non-sufficient funds.

You are responsible for the timely payment of your account. We reserve the right to send your account to collections in the of nonpayment. 
 *

NON-COVERED CODES: We KNOW there are tests we administer that are not covered or are deemed ‘experimental’ by insurances and subsequently are not covered.

If your plan indicates a CPT Code is not covered or is deemed "experimental" and they deny it, you are responsible for the Patient Rate or deductible rate dictated by your insurance company. We do our best to verify and inform you on your cost Estimate if we know this in advance.

92517, 92518, 92519 – Cervical VEMP, Ocular VEMP, BOTH respectively - If denied: up to $150, If pushed to your deductible: up to $200.

92548/92549 - Platform Posturography - $120 for the evaluation, $75 for 30 minute therapy, $50 for reassessment. We KNOW Aetna, Cigna, and some UHC NEVER cover this test. This will be on your estimate.

s9476 Vestibular Rehabilitation - may not be covered based on your policy- review your estimate.

UNLISTED CODES: MDBI offers testing and treatment that no other facility offers. We administer 2 tests that do not currently have CPT codes so a generic code is used for insurance. This means we DO NOT know if your insurance will cover them. We submit all documentation to the insurance company for you, however, be advised that if your insurance DENIES the code or pushes it towards your deductible, YOU will be required to pay a percentage of the billed rate, which is determined by your insurance company. If you have a large deductible, we will collect the estimated ‘Patient Rate’ AT TIME OF SERVICE and you will be billed for any additional charges. You are acknowledging that you understand certain procedures are new and state of the art and may not be covered by insurance.

All of this information will be on the ESTIMATE  provided to you BEFORE your appointments. You can also request this prior to any treatments as well. This is an ESTIMATE pulled from your insurance company detailing what they expect you to be responsible for at the time of service. An estimate is NEVER a guarantee of payment by insurance. 


Please acknowledge that you have read our financial policy and you agree to your financial responsibility for your testing. (TYPE NAME)


 *
By signing this form, I agree that my initials provided above acknowledge my receipt and review of the financial policy.
Patient Name (Electronic Signature):
 *
Date: *
MM
/
DD
/
YYYY
Responsible Party: *
Date: *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms