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THIRD PARTY CLAIMS: THIS OFFICE DOES NOT BILL THIRD PARTY CLAIMS (MOTOR VEHICLE ACCIDENTS, INJURIES SUBSTAINED SHOPPING, HOMEOWNERS LIABILITY CLAIM, ETC.) PAYMENT IS EXPECTED AT THE TIME OF SERVICE AND A BILLING/RECEIPT WILL BE ISSUED TO YOU FOR BILLING PURPOSES.
WORKERS COMPENSATION CLAIMS: WE REQUIRE PRIOR AUTHORIZATION FROM YOUR EMPLOYER BEFORE YOU CAN BE SEEN FOR YOUR INITIAL OFFICE VISIT. IF YOUR CLAIM IS DENIED, EVEN THOUGH YOUR EMPLOYER AUTHORIZED THE VISIT, YOU WILL BE HELD FINANCIALLY RESPONSIBLE FOR PAYMENT IN FULL ON YOUR ACCOUNT.
NARCOTIC/PAIN MEDICATION: IF THESE MEDICATIONS ARE PRESCRIBED FOR YOU WE REQUIRE A COPY OF YOUR DRIVERS LICENSE AND YOUR THUMB PRINT.
PATIENT/PARENT/AUTHORIZED OR LEGAL GUARDIAN SIGNATURE
( SIGNATURE VERIFIES YOU HAVE BEEN NOTIFIED OF THE ABOVE FOR THIS OR ANY FUTURE VISITS THAT MAY APPLY)
OUR POLICY IS PAYMENT AT THE TIME OF SERVICE –WE ACCEPT CASH, VISA, MASTERCARD, DISCOVER, OR CHECK
Co-pays and deductibles are due at the time of service.
TREATMENT AUTHORIZATION – I grant permission to the physician and staff as directed by the physician of Hilltop Medical Clinic/Hilltop Medical Clinic West to perform any medical or surgical treatment and to administer such local anesthetics and/or drugs as may be deemed necessary in the diagnosis and treatment of said patient for today and future office visits. FOR A CHILD PATIENT – I understand by authorizing treatment I am also accepting responsibility to be the financial party on this and all future office visits for this minor patient until (s)he is legally considered and adult at age 18.
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