Eileen Benway, MD 1844 San Miguel Drive, Suite 310, Walnut Creek, CA 94596 (925) 937-6000 www.bbdocs.com

PATIENT FINANCIAL RESPONSIBILITY CONSENT STATEMENT

Welcome to the office! Please read carefully the following important information.

The physicians who share this office are not partners or otherwise affiliated in the same medical practice. We are independent practitioners who simply share office space, equipment and staff in their separate practices. We are not responsible for each other’s practices or patients except in the case of emergency coverage when the patient’s primary physician is not available to offer care.

I am a participating provider with most insurance companies. Dr. Birdsall and I endeavor to contract with the same insurance companies to make emergency and on-call coverage of each other’s patients easier. However, the list of accepted insurances is subject to change at any time and not all plans under all companies are accepted. In order to avoid unexpected charges, please confirm that your particular health benefit plan is accepted by my practice. You should reach out to your carrier when you initiate care here to familiarize yourself with the limits of your policy and what it will (and will not) provide coverage for. We do our best to guide patients through this process, but ultimately it is impossible to keep abreast of the requirements in the thousands of insurance products on the market today. It is an individual patient’s responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.

Please be aware that, except as contractually agreed otherwise, patients are ultimately responsible for insuring payment for all medical services provided. If a carrier denies payment for services because a plan requirement was not met, services were considered “noncovered”, the plan benefits were exceeded, care is considered medically unnecessary, or treatment is considered experimental, among other reasons, patients will be held accountable for those charges.

Please bring your insurance card with you to every visit and notify my staff of any changes in your coverage. if your insurance requires you to pay a co-payment and/or deductible, you will be required to pay that portion of the cost of your visit at the time of service, preferably at the time of check in and registration at our front desk. If you do not pay your co-payment at the time of service, we will bill you for this, along with a billing fee of $15.

All patient accounts are to be paid at the time of service. We will ask you for payment on all outstanding balances. We accept cash, checks and major credit cards. Checks that are returned unpaid from your account will be assessed an additional $25 NSF fee. Financial problems should not be a deterrent to obtaining medical care. If you require special arrangements, please feel free to contact our billing service or our office manager for a private consultation.

LABWORK Throughout the course of your care, blood and tissue samples may be sent to a variety of clinical laboratories. If your insurance plan contains restrictions or limitations on lab work, please make that known to our clinical staff before your blood is drawn or sent for processing. Provided you let us know in advance of a test being performed, we can in many instances route routine samples to labs that will accept your insurance. There may be some specialty tests required that only a limited number of reference labs are capable of performing. In those instances patients will be responsible for the fees incurred at those labs if their insurance does not participate with them.

Please be aware that we have no role in or control over billing issues related to clinical laboratory fees. If you have questions about bills received for laboratory charges or insurance coverage available to you, please contact the clinical laboratory in question and/or your insurance carrier. We regret that our billing staff cannot be of assistance to you in mitigating laboratory charge issues. OTHER FEES NOT COVERED BY INSURANCE

Appointment Cancellations: When you make an appointment, that time is reserved specifically for you. Unfortunately, when a patient doesn’t come to their scheduled appointment, another patient loses an opportunity to be seen. Therefore, if you need to cancel or re-schedule, you are requested to notify us as soon as possible, but no later than 24 hours in advance. Appointments cancelled without 24 hour notice may be assessed a cancellation fee of $50. In the event that two patients in the same family are booked into 2 consecutive appointments (a “double”), please be advised that a cancellation fee of $50 per child will be charged if the appointment is no-showed or canceled with less than 48 hours notice prior to the appointment. Habitually cancelling your appointments may cause me to ask you to find another physician for your healthcare needs. Reminder calls are a courtesy we provide when possible, but the responsibility for remembering your appointments is yours.

Completion of Forms: Because of the high demand for the physician’s time with patients, if you require forms to be completed for school, work or legal purposes, there will be a charge of $20 per form. This fee covers the time the physician uses to compile the information from your chart and complete the form. Forms that are completed during a patient exam are not charged the $20 fee.

Copies of Medical Records: As a patient, you have the right to have access to your medical records. This office charges patients a fee of $25 for a copy of your records. This fee is not payable by your insurance plan and is expected from the patient, prior to release of your medical record.

PATIENTS WITHOUT INSURANCE: As a courtesy for patients who do not have health insurance coverage, there is a discounted self-pay fee schedule. Patients who have no insurance are expected to pay for services at the time of service and will receive a discount from the normal fee schedule. If you are interested in knowing an estimate of fees for services rendered, please contact a staff member.

BILLING QUESTIONS: I have contracted with Navigant for billing and collection services. Billing questions and concerns should be directed to their office at 855-270-2246. When you receive a statement from me and have questions about your account, you can call the toll free number listed at the bottom of the statement, which will direct you to the billing staff. They will be happy to answer your questions or concerns, and in cases of financial hardship may be able to develop a payment plan with you. Failure to pay your balance due to us may result in the referral of your account to an outside third party collection agency. Referring your delinquent balance may affect your credit rating.

Our staff is committed to excellence in customer service and quality care of our patients. Feel free to contact our office for questions or concerns regarding your financial and health insurance issues.

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