LOWER MERION NEUROLOGY, PC

Paoli Medical Commons 250 W Lancaster Ave, Suite 260 Paoli, PA 19301
Narberth Professional Building 145 N Narberth Ave, First Floor, Narberth, PA 19072
Phone: 484 413 2572 Fax: 484 413 2611
e-mail: info@LowerMerionNeurology.com; web: www.LowerMerionNeurology.com

Patient Financial Responsibility Form

1. Patient Responsibility:

I understand that I am financially responsible for all charges related to my care, including but not limited to co-payments, deductibles, co-insurance, and non-covered services.

2. Insurance Verification:

I acknowledge that it is my responsibility to verify that my insurance plan provides coverage for services rendered by Lower Merion Neurology. I understand that any coverage determination made by Lower Merion Neurology is not a guarantee of payment.

3. Referral:

If my insurance plan requires a referral, it is my responsibility to obtain the referral from my primary care practice before I receive services at Lower Merion Neurology. I understand that in the absence of a referral, my insurance may deny the payment of services and I shall be responsible for paying full amount of the claim.

4. Billing and Payment:

I agree to pay any amounts not covered by my insurance, including co-pays and deductibles, at the time of service unless other arrangements have been made. I also agree to respond promptly to any billing statements and to make payments as required.

5. Contacting the office by phone or email:

I understand that when I contact the doctor's office by phone and email, some or all of those encounters may be billed to my insurance. As determined by my insurance, I will be financially responsible for any charges payable by me.

6. Collections:

If my account becomes delinquent and is sent to a collection agency, I understand that I am responsible for all collection costs and legal fees incurred in the collection of my debt.

I acknowledge that I have read and understood the financial policies of Lower Merion Neurology. I consent to the financial terms outlined above.