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Signature

Please review the form, then enter your full name, and sign your name in the box below.

Patient Name
Signature (Use your mouse cursor to sign your name. Click in the box to the right and hold down the mouse button and drag your mouse cursor to sign your name. Release the mouse button when you're done signing your name.)

Copayments, coinsurance, and deductible payments as determined by your agreement with your insurance carrier are due at the time of service. We will file your insurance claim if you agree to have your insurance company pay the doctor directly for services provided. Not all insurance plans cover all services; in the event your insurance plan determines a service to be “not covered,” you will be responsible for payment. Payment is due upon receipt of statement from our office.

If you have no health insurance, payment is due at the time of service. There will be a $25 fee for returned checks.

In fairness to other patients and the physician, we request 24 hours notice to cancel an appointment. You may be charged $25 for a missed appointment. Missing more than two appointments without providing notice are grounds for discharge from the practice.

I agree to the above financial policy. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this health care provider to release information necessary to secure the payment of benefits from my insurance company.

Referral Requirement

I am seeking treatment from Eric Tiblier, MD and understand that if my medical insurance company requires a referral to see a specialist, I am responsible for ensuring that the referral has taken place. If I have not obtained a required referral at the time of my appointment, I understand that I am financially responsible for any changes incurred during that office visit, if not covered by my insurance company.

Notice of Privacy Practices

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”). I have certain rights to privacy regarding my protected health information. I further understand that this information can and may be used for any of the following:

To conduct, plan and direct my care and follow-up with the multiple healthcare providers who may be directly or indirectly involved in the treatment(s).
To obtain payment from third party payers (insurance, etc.).
To conduct normal and required healthcare operations such as quality assessments and physician certifications.

I have been informed by Dr. Eric Tiblier, P.A. of their Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have had the opportunity to review the entire Notice of Privacy Practices prior to signing this consent.