Developmental Diagnostics

Developmental Diagnostics

Statement of Financial Responsibility

Patient Name:______Date of Birth:______

The staff of Developmental Diagnostics appreciates the opportunity to provide high quality care for patients and their family. It is our obligation to do this in a cost-effective manner. By participating in this care, you are assuming a financial responsibility. This responsibility obligates you to ensure payment is made in full to Developmental Diagnostics for our services. As a courtesy, we will bill your insurance carrier on your behalf; however, you are responsible for the payment of any deductible, co-payment and/or co-insurance amount as determined by your contract with your insurance carrier or any amounts not covered by your insurer.

I understand that it is my responsibility and not the responsibility of Developmental Diagnostics to know if my insurance will pay for any services I receive.

I understand that it is my responsibility to know if the provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the provider I am seeing is not an in-network provider, it may result in claims being denied or higher out-of-pocket expense to me. I understand and agree to be financially responsible for all charges.

I understand that it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amounts, or any other type of benefit limitation for the services I receive.

I authorize my insurer to pay any benefits due to me under my policy directly to Developmental Diagnostics the full amount of bill incurred by me or the above named patient. I authorize the provider to release all medical information necessary to process this claim.

I have read and understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments.

I have read and understand the above information, and I agree to the terms described:

Signature:______Date:______

Responsible

Party Name:______

(Print Name if Different From Patient)