Financial Responsibility Form

 

  1. INDIVIDUAL’S FINANCIAL RESPONSIBILITY

    1. I understand that I am financially responsible for my health insurance deductible, coinsurance, or non-covered service.

    2. Co-payments are due at time of service.

    3. If my plan requires a referral to BridgeCare Specialists of Michigan, I must obtain it prior to my first visit.

    4. If my health plan determines a service to be “not payable,” I will be responsible for the complete charge and agree to pay the costs of all services provided.

    5. If I am uninsured, I agree to pay for the medical services rendered to me at time of service, unless a payment schedule has been authorized by us in advance.
       

  2.  INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
    I hereby authorize and direct payment of my medical benefits to BridgeCare Specialists of Michigan on my or my dependent’s behalf for any services furnished to me or my dependent by the providers.
     

  3. AUTHORIZATION TO RELEASE RECORDS
    I hereby authorize BridgeCare Specialists of Michigan to release to my insurer, governmental agencies, or any other entity financially responsible for my or my dependent’s medical care, all information, including diagnosis and the records of any treatment or examination rendered and needed to substantiate payment for such medical services, as well as information required for precertification, authorization, or referral to other medical provider(s).
     

  4.  MEDICARE REQUEST FOR PAYMENT
    I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in BridgeCare Specialists of Michigan. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.