Mehling Orthopedics of New York, PLLC

800 Montauk Highway

West Islip, NY 11795

(631) 893-3903

GUARANTEE AGREEMENT INDIVIDUAL’S RESPONSIBILITY FOR NON-COVERED SERVICES

In consideration of services rendered by Dr. Brian Mehling, Dr. Pavel Yufit, and Tara Gianni, RPA-C to the undersigned patient, the undersigned promises to pay Mehling Orthopedics any co-payment, co-insurance, deductibles, or any other charges required to be paid by my health insurance company. In addition, I promise to pay for all services that are not covered by my health insurance plan. In case of denial or termination of benefits, or in the event that I fail to inform you of any changes to my insurance coverage, I, the undersigned, understand that I am responsible for payment of services rendered.

In the case of a denial from No-Fault, the Worker’s Compensation Board, my Worker’s Compensation carrier, or termination of my Orthopedic benefits from any of the aforementioned, I the undersigned am responsible for payment in full for any and all services rendered to me by the medical providers of Mehling Orthopedics.

ASSIGNMENT OF BENEFITS

I hereby assign to Dr. Brian Mehling, Dr. Pavel Yufit, and Tara Gianni RPA-C, all monies and/or benefits to which I am entitled from my insurer/HMO/third party payer/No-Fault Carrier/Worker’s Compensation Carrier/Government Agencies or those who are financially responsible for payment of my medical care.

AUTHORIZATION TO RELEASE RECORDS

I hereby authorize Dr. Brian Mehling, Dr. Pavel Yufit, and Tara Gianni RPA-C to release to my insurer/HMO/third party carrier/Government Agencies / Worker’s Compensation and No-Fault carriers to whomever is financially responsible for payment of my medical care, all information needed to substantiate payment for such medical care and, if required, of pre-certification/authorization/prior approval purposes.

It is, however, expressly understood that there will be no obligation of the undersigned party to pay for any services which are not Medically Necessary or are improperly billed.

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Signature of Patient/Authorized Representative Date

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Witness Initials