Would Like to Assist You with Your Insurance Claim Filing and Other Financial Issues As

We understand that you may not be feeling your best when seeing a physician. In recognition of this, Western Surgical Group

would like to assist you with your insurance claim filing and other financial issues as best as we can. Our intent is to reduce your

financial stress and allow you time to heal. In order to accomplish this, we must ask that we have all the information provided

to us at the time of your first visit. In return for your cooperation, our office can devote more time to patient care and less time

to paperwork.

Please bring your insurance card(s) and picture identification with you each time you visit our office.

HEALTH PLAN OBLIGATION:

I understand that Western Surgical Group maintains contracts with various health plans and government programs. I understand

that I am responsible for determining whether my health plan or government program contracts with WSG for the services

I will be provided. I also understand that I am responsible for ensuring that appropriate authorizations have been received or notifications

have been given, as required by my health plan. I also understand that I am obligated individually to pay any applicable co-pays,

co-insurances, deductibles, or other amounts as well as any charges for services rendered to me to the extent that those services

are not covered by a contract between WSG and my health plan or government program.

ASSIGNMENT OF INSURANCE BENEFITS:

I authorize direct payment to Western Surgical Group care providers of any benefits to which I am entitled arising out of any policy of insurance or government program including, but not limited to, healthcare benefits, workers compensation coverage benefits, and medical payments coverage benefits, for services provided to me, including emergency services, hospitalization and outpatient services. I understand that I am financially responsible for any charges not paid pursuant to this assignment and/or other contractual arrangements. For my convenience, I intend that this signed form will serve as a single assignment of benefits and authorization to bill for all parties providing care to me.

CHARGES:

I understand that I will receive emergency medical treatment regardless of my ability to pay at the time of treatment. I further understand that charges for services provided to me for which I do not have insurance are payable in full at presentation of the bill unless application is made in writing for time payment arrangements. I accept full responsibility for all charges. If my account is referred to an attorney or collection agency for collect, I will be responsible for reasonable attorney’s fees and collection expenses incurred by WSG, including interest at the applicable statutory rate.

In addition, be aware of the following regulations set by the following payers:

MEDICARE PATIENTS

We are participating providers and bill Medicare and Medi-Gap Insurance. All balances and deductibles are due

within 30 days after Medicare has paid.

COMMERICAL INSURANCE

We will bill your insurance and send a statement showing the remaining balance. If your insurance does not pay

within 60 days, the balance will be your responsibility. Western Surgical Group may not recognize usual and

customary discounts suggested by your carrier.

MEDICAID PATIENTS

You must bring your current Medicaid card with you each visit. We cannot bill for services without it.

SELF PAY PATIENTS

Be prepared to pay a minimum of $100.00 deposit for each office visit. You will be billed for the balance, if any. A $500.00 deposit is

required before surgery can be scheduled. Payment plans are available for balances due.

If you would like to pay your office visit in full at time of service a discount will be offered. ______initial

COLLECTION POLICY

You will receive 2 statements and one phone call addressing any balances due. If arrangements are not made within this time frame,

the balance will be forwarded to a Collection Service. We accept all forms of payment. Should you have any questions, please

request to speak to a collections specialist. ______initial

I hereby authorize Western Surgical Group/Western Bariatric Institute to appeal any and all claims with my insurance company on my behalf. ______initial

I authorize the release of any medical or other information necessary to process my Insurance claims. I authorize payment of medical

benefits to Gomez, Kozar, McElreath, Smith, Professional Corporation, DBA Western Surgical Group for all services.

Patient/Guardian Signature: ______Date______