Assignment of Benefits
I hereby assign to Valera Medical, P.A., and its affiliates, Valera Medical, P.C., and Valera Medical Corporation (collectively, “Group”) all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any insurance payer, including Medicare, private insurance and any other health plan for medical treatment rendered by Group. The assignment will remain in effect until revoked by me in writing. I authorize the release of pertinent information necessary to process my medical claim. I also authorize direct payment to Group of all insurance benefits payable to me for such medical treatment. In the event an insurance payer pays me directly, I agree to immediately pay such amounts to Group.
I understand that my insurance payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying Group for any and all amounts not paid by my insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand that if my insurance requires a referral, I am responsible for obtaining one prior to my appointment. In the event any collection action is necessary to collect amounts I owe to Group, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.
I acknowledge that:
- There is a $25 penalty if you don’t show up to your scheduled appointment, or if you cancel or reschedule within 24 hours of the scheduled time. This applies to all patients except those enrolled under Medicaid. Valera Medical PC will make a best effort attempt to charge the card on file within 60 days of the appointment date.
- If you are more than 15 minutes late to your appointment, it will be considered a no-show. You will have to reschedule your appointment with your provider.
- If you cancel or reschedule your appointment outside of 24 hours of the scheduled appointment, there is no financial penalty.
- If you no-show for two consecutive appointments or when missed appointments contribute to at least 50% of the overall scheduled appointments during a 3 month period, you will be discharged from the service. If you wish to restart services we cannot guarantee that you will be matched with the same provider.
- Canceled and rescheduled visits count towards termination after the 3rd occurrence in a row or when missed appointments contribute to at least 50% of the overall scheduled appointments during a 3 month period.
- I am required to place a credit card on file, which will be charged for any copays and/or deductibles and coinsurance. Under certain circumstances, the provider on the claim submitted to your insurer may be different from the provider who rendered the services to you. The name listed is the supervisor of your provider. Valera Medical PC will make a best effort attempt to charge the card on file within 60 days of the appointment date.
I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.