Loading...

Excellent patient care inspired by compassion

MOUNTAIN VIEW MEDICAL GROUP Secondary Insurance Information for Hospital / Surgical Care Only

PLEASE DO NOT ABBREVIATE ANY INFORMATION

Patient Information
Insurance Subscriber (if other than patient)
Secondary Insurance Information

Patient's Billing Agreement PLEASE READ CAREFULLY!
1) I understand that if the insurance claim is denied due to incorrect information that I have provided, I will be billed and payment in full will be due immediately.
2) I hereby request and authorize Mountain View Medical Group physicians & personnel to deliver medical care to me.
3) I verify that if I am seeking primary care, I have designated a Mountain View Medical Group physician as my primary care physician with my insurance company. I understand that if the insurance company denies paying my claims because one of these doctors WAS NOT the designated PCP in effect at the time of the visit, that I am responsible for paying in full for all services provided.
4) If Mountain View Medical Group is contracted with my insurance company, I authorize assignment of payment directly to the doctor for services provided me. I understand that Mountain View Medical Group will file the claim with my insurance company and that I am responsible for following up with my insurance company to insure my claim is paid within 60 days of the date of service.
5) I understand that, under the terms of the contract of the insurance company, co-payments must be paid at every visit.
6) If I have insurance that Mountain View Medical Group is not contracted with, I agree to pay the bill in full at the t ime services are provided. I understand that Mountain View Medical Group will file a claim with my primary insurance company (except Tricare) as a courtesy, but that it is my responsibility to follow up with my insurance company to insure personal reimbursement by them.
7) I understand that if I have no insurance coverage, I agree to pay the balance in full at the time services are provided.
8) I understand that medical records are the property of the physicians of Mountain View Medical Group; however, I am entitled to copies, with sufficient advanced notice, upon my written request. I understand that there may be a charge for these copies.
9) I hereby authorize the release of my medical information to the insurance company concerning any illness and treatment.
10) I acknowledge that I can obtain a copy of the Mountain View Medical Group's Privacy Rights / HIPAA Information from the front desk upon my request.
11) I understand that a $50.00 fee may be charged for all appointments missed or not canceled at least 24-hours in advance.
12) I understand that if my account becomes past due, Mountain View Medical Group will take the necessary steps to collect this debt, which will also include all associated collection fees, attorney/legal fees, and court costs.
13) I understand that I am responsible for knowing the benefits of the specific insurance plan(s) I have purchased, and that MVMG is not responsible for interpreting these benefits, or for how my insurance company(ies) process the claims. I further understand that MVMG cannot serve as an intermediary between my insurance company and myself in claims processing or claims disputes; that I must personally resolve these matters with my insurance company.
14. I understand that I am responsible for all services not covered by my insurance.
15. I understand that I am responsible for all balances applied to deductible, co-insurance and/or copay.

* You must enter your initials into the field below to submit this form. By entering your initials, your are agreeing to/accepting the "Financial Terms" (above).

Please confirm that you are a Mountain View Medical Group patient: