Financial Agreement - 1800 MCDONOUGH ROAD SURGERY CENTER LLC.
I (we) (Names of both patient and primary insured party), as the patient-insured(s)-assignor(s) execute this Payment Guarantee, /Assignment of Insurance Benefits for and in consideration of the medical services to the above patient, I (we) agree to pay the established rate of the 1800 MCDONOUGH ROAD SURGERY CENTER LLC. and hereby assign all of my (our) rights to receive health insurance benefit payments or reimbursements or health plan benefit payments or reimbursements for health care services performed on behalf of myself or any family member. I (we) understand that this is an irrevocable assignment which grants 1800 MCDONOUGH ROAD SURGERY CENTER LLC. (as assignee) the absolute right to directly receive payments for covered health care services. I hereby direct my (our) health insurance or health plan benefit administrator or any of its administering subcontractors or agents to pay benefits otherwise payable to me directly to the 1800 MCDONOUGH ROAD SURGERY CENTER LLC.
I (we) (Names of both patient and primary insured party), as the patient-insured(s)-assignor(s) hereby irrevocably appoint and grant all of my (our) rights to receive or enforce healthcare benefit payments to the 1800 MCDONOUGH ROAD SURGERY CENTER LLC, its administrators or assigns shall have authority to receive health care benefit payments, attach, levy, recover, or receive all such sum or sums of money which are or may hereafter become due, owing and payable for services rendered by the 1800 MCDONOUGH ROAD SURGERY CENTER LLC. on behalf of myself or any family member.
On the day of surgery, if my surgery is canceled after admission by my physician and/or anesthesiologist due to medical or other extenuating circumstances, I understand that my payer will be billed the established rate of 1800 MCDONOUGH ROAD SURGERY CENTER LLC. I understand that I am financially responsible for all surgical center and physician charges not covered by my insurance plan.
1800 MCDONOUGH ROAD SURGERY CENTER LLC. and its administrators or assigns is (are) hereby granted full power and authority to do and perform all and every act and thing whatsoever required and necessary to obtain payment for medical services rendered that the patient-assignor might or could do if personally present.
If it becomes necessary to proceed with collection and my account is turned over to a collection agency, in addition to the principle amount owed plus 1.5% interest, I hereby agree to pay forty (40%) of the unpaid balance as collection fees. I further agree to pay reasonable attorney fees and court costs arising out of any litigation concerning the collection of this account.
I authorize the physicians and 1800 MCDONOUGH ROAD SURGERY CENTER LLC. to release any information requested in the course of my treatment to the insurance companies, payers, or third party for collection of any and all charges incurred in the course of my treatment.
(No signature of Patient, Insured, or Authorized Person is Required at this time)