Neil J. Negrin, M.D.
3875 Austell Road suite 201 Austell, GA 30106
Phone:770-819-1777 Fax:770-819-1730
I hereby assign, transfer, and convey all my rights, title, and interest to medical reimbursement under my insurance policy(s) to Neil J. Negrin, M.D., LLC. It is understood that whether I sign as agent, patient, or as guarantor that I am directly responsible and will pay for service rendered and not paid by my insurance agency. An assignment of benefits by any insurance policy or medical reimbursement plan shall not be deemed a waiver of Neil J. Negrin, M.D., LLC right to require payment directly for the undersigned or the patient. Neil J. Negrin, M.D. expressly reserves the right to require such payment. I agree to assume full financial responsibility for the payment of all charges in the event that they are not paid for by my insurance. I waive the necessity of prior suit and agree to pay the charges on demand.
Medicare Patient: I certify that the information given in applying for Medicare payments is true and correct. I authorize Neil J. Negrin, M.D. or others involved in my care to release medical or personal information about me to the Social Security and Health Care Financing Administration, (HCFA) or its carriers or intermediaries for the purpose of Medicare claims. I request direct payment or my authorized Medicare benefits to Neil J. Negrin, M. D.. Should the account be referred to any agency for collection (collection agency or attorney), the undersigned shall pay all responsible attorney fees, collection costs, and interest. I assign payment of all insurance benefits to physicians providing professional services and Neil J. Negrin, M.D.
I have read this form and understand its contents. I have an opportunity to ask questions that have been answered to my satisfaction.
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Specializing in Joint Replacement Surgery