Patient Financial and Insurance Agreement

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We are committed to providing you with quality medical care. Our professional fees have been determined through careful consideration, and we believe these fees are reasonable and reflect other area physicians’ charges. We are happy to discuss with you any questions you may have concerning your bill or charges before your treatment is begun.

We accept many, but not all, insurance plans. Before making an appointment, please call our office, or email or fax us a copy of your insurance card, and we will verify if we participate with your insurance plan. Our office will file claims directly with your insurance carrier for services where covered benefits have been verified. Insurance verification does not guarantee your insurance will pay for services. Payment of co- insurance, co-pays, deductibles or fees for non-covered services, when applicable, is required at the time of service.

Each time you make an appointment, it is your responsibility to make sure Dr. Jaliman is currently accepting your plan and that you have obtained the necessary referrals when needed. Verification of your plan benefits/coverage is required. Often this verification requires us to share the reason for your visit with a managed care plan.

We accept assignment of Medicare benefits. However, you may be asked to sign a waiver to acknowledge your understanding of your responsibility to pay for services not covered by Medicare.

We accept cash, debit cards, Visa, MasterCard, American Express and Discover for payment of services. We encourage you to leave your credit card on file to ensure that any balance owed is paid accordingly.

I have read, understood and agreed to the above office and financial policies. I hereby attest that I have given accurate information regarding my insurance and demographics and understand that I am solely responsible for payments not made by my insurance company or non-covered services.

Credit Card Number: _______________________________________________

Exp: ______________ CVV Code: ___________________

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Patient Signature

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