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Savannah Neurology Specialist, PC

Physician Practice Financial Policy and Release of Information The following is a statement of our Financial Policy for services provided within our office and do not apply to any testing or diagnosis procedure performed outside of this physician practice. We require you to read and sign this document prior to treatment by this facility.

Patient Responsibility All professional services rendered are charged to the patient and are due at the time of the service. As a courtesy this practice will file your claim with your insurance carrier however, the patient or responsible party is ultimately responsible for the charges not covered by your contract with the carrier. Any co-payments or deductible amounts not satisfied with your carrier are due at the time of service.



Insurance carriers typically do not cover all medical costs. Some pay fixed allowances for each procedure and office visit while others pay only a percentage of the costs. Surgical procedures, labs, and other outpatient procedures may have higher co-payment or fall under the deductible. It is the patient’s responsibility to understand their insurance coverage and to notify us of any changes.



When you receive a statement from Savannah Neurology Specialist PC, you are required to pay the balance due upon receipt of the statement. If for some reason you do not agree with the balance due amount, you are to contact a billing representative at the phone number noted on the statement. DO NOT IGNORE THE BILL, as it may result in placing the balance with an outside agency for recovery.



Authorization for Treatment and to Release Information The signature below serves as authorization for medical treatment by the physician, Physician’s assistant, nurse practitioner, or nurse for the named patient. It also provides Authorization for Savannah Neurology Specialist PC to furnish and/or release any information necessary to insurance carriers, third party administrators, self-insured plan administrator, and/or other health benefit payer representatives in order to process health care claims incurred at this office or utilization review or quality assurance. This authorization also serves as permission to obtain a copy of your complete medical record from other physician practices or medical facilities. A copy of this authorization may be used in place of the original in obtaining the medical records. I understand that I may withdraw this authorization to release medical information at any time, communicated to the practice either in writing or verbally, followed by written withdrawal.



Appointment of Representative and Authorization to Appeal I appoint Savannah Neurology Specialist PC as my representative to appeal any claims on my behalf.


I understand that I am financially responsible to Savannah Neurology Specialist PC for any balance not covered by the insurance carrier.


I hereby assign and authorize my insurance benefits to be paid directly to Savannah Neurology Specialist PC.

Patient Name (please print)

Signature of Patient or Responsible Party


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