Orthopaedic Center of Okeechobee, PA

Orthopaedic Center of Okeechobee, PA

Bradford A. Slutsky, M.D.

1920 Hwy. 441 North

Okeechobee, FL 34972

Release of Insurance Information and Payment to Physician

In order to submit a claim for payment to us for services covered under your policy, we must have your authorization to release medical information to your insurance carrier.

MEDICARE AND MEDICAID

I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of the authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.

Signed: Date:

ALL OTHER INSURANCE

I hereby authorized Dr. Slutsky to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries to issue payment check(s) direct the physician(s) rendering the covered services until I revoke this authorization in writing.

I authorize Dr. Slutsky to furnish complete information requested by my insurance carrier or its intermediaries regarding services rendered.

I further agree that I am responsible for paying any balances, which remain after insurance payments have been made.

Signed: Date:

NON-PPO AGREEMENT

By signing below, I acknowledge that I have been informed that the Orthopaedic Center of Okeechobee, P.A. is not on my insurance network (out-of-network). Therefore, I understand that out of network benefits will apply and I will be responsible for any amounts not allowed or covered by my insurance plan.

Signed: Date:

SELF-PAY AGREEMENT

By signing below, I understand that the Orthopaedic Center offers certain incentive discounts to patients without insurance. The discount applies only at the time of service. If the account balance is not paid in full at the end of treatment, all discounts will be reinstated and I will be fully responsible for any charges for services rendered and any collection fees associated with the recovery of my account balance.

Signed: Date: