Currie and Hecht Oral and Maxillofacial Surgeons, PC

ASSIGNMENT OF INSURANCE BENEFITSI authorize and assign the health insurance benefits to which I am entitled to CURRIE & HECHT ORAL AND MAXILLOFACIAL SURGEONS, P.Cand to CENTER FOR AMBULATORY ANESTHESIA, INCLUDING (herein known as “Providers”) for their servicesThis assignment will remain in effect until revoked by me in writingA photocopy of this assignment is to be considered as valid as the originalI understand that I am financially responsible for all charges whether or not paid by my insuranceI understand that my plan may not compensate my Providers for their anesthesia services and I will therefore be totally responsible for all charges, I hereby authorize the Providers, to whom I assign benefits, to release any information about me necessary to process their claimIn the event that this account must be assigned to collection, I agree to pay all costs, including reasonable attorney feesIn addition, I hereby grant alien to these Providers - against any settlement, claim judgment, or verdict I may receive as a result of my accident for the payment of the Provider's bills.(Signatures proved by physician, anesthesiologist and patient along with a witness on 3/02/2015) OUR FINANCIAL POLICY CURRIE & HECHT ORAL AND MAXILLOFACIAL SURGEONS, P.C.We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any timeYour clear understanding of our Financial Policy is important to our professional relationshipPlease ask if you have any questions about our fees, Financial Policy or your responsibility PAYMENT OF SERVICES RENDERED ARE DUE AT THE TIME OF SERVICEWE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AND DISCOVER Regarding InsuranceIf you have insurance, we will help you receive maximum benefitsAny insurance claim will only be completed if we are furnished full insurance company informationOtherwise, you are responsible for payment at time of service.INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANYWe will inform you if we are a party to your insurance contract and will handle your claims according to our agreement with the insurance companyWe file insurance claims as a courtesy to our patients with those insurances we participate with, otherwise you are responsible for payment and we will, in turn, give you the necessary receipt for you to submit for reimbursementIf you have any questions regarding the payment allowance by your insurance company, our insurance department will be happy to assist youPlease have your "Explanation of Benefits” on hand when you call our officeWe will NOT become involved in the dispute between you and your insurance company regarding deductibles, copayments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessaryYOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF YOUR ACCOUNT.THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICYPLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNSI understand that I am financially responsible for all charges whether or not paid by my insuranceIf I have not made any attempt to make payment or set up a payment schedule for my account, I understand that after my account is days delinquent, I will be sent to a collection service and may be charged additional fees.Responsible Party Signature Date: (Consumer's signature provided on 03/02/2015)

ASSIGNMENT OF INSURANCE BENEFITSI authorize and assign the health insurance benefits to which I am entitled to CURRIE & HECHT ORAL AND MAXILLOFACIAL SURGEONS, P.Cand to CENTER FOR AMBULATORY ANESTHESIA, INCLUDING (herein known as “Providers”) for their servicesThis assignment will
remain in effect until revoked by me in writingA photocopy of this assignment is to be considered as valid as the originalI understand that I am financially responsible for all charges whether or not paid by my insuranceI understand that my plan may not compensate my Providers for their anesthesia services and I will therefore be totally responsible for all charges, I hereby authorize the Providers, to whom I assign benefits, to release any information about me necessary to process their claimIn the event that this account must be assigned to collection, I agree to pay all costs, including reasonable attorney feesIn addition, I hereby grant alien to these Providers - against any settlement, claim judgment, or verdict I may receive as a result of my accident for the payment of the Provider's bills.(Signatures proved by physician, anesthesiologist and patient along with a witness on 3/02/2015)
OUR FINANCIAL POLICY CURRIE & HECHT
ORAL AND MAXILLOFACIAL SURGEONS, P.CWe are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any timeYour clear understanding of our Financial Policy is important to our professional relationshipPlease ask if you have any questions about our fees, Financial Policy or your responsibility.
PAYMENT OF SERVICES RENDERED ARE DUE AT THE TIME OF SERVICEWE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AND DISCOVER Regarding InsuranceIf you have insurance, we will help you receive maximum benefitsAny insurance claim will only be completed if we are furnished full insurance company informationOtherwise, you are responsible for payment at time of serviceINSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANYWe will inform you if we are a party to your insurance contract and will handle your claims according to our agreement with the insurance companyWe file insurance claims as a courtesy to our patients with those insurances we participate with, otherwise you are responsible for payment and we will, in turn, give you the necessary receipt for you to submit for reimbursementIf you have any questions regarding the payment allowance by your insurance company, our insurance department will be happy to assist youPlease have your "Explanation of Benefits” on hand when you call our officeWe will NOT become involved in the dispute between you and your insurance company regarding deductibles, copayments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessaryYOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF YOUR ACCOUNTTHANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICYPLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS
I understand that I am financially responsible for all charges whether or not paid by my insuranceIf I have not made any attempt to make payment or set up a payment schedule for my account, I understand that after my account is days delinquent, I will be sent to a collection service and may be charged additional feesResponsible Party Signature Date: (Consumer's signature provided on 03/02/2015)

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ASSIGNMENT OF INSURANCE BENEFITSI authorize and assign the health insurance benefits to which I am entitled to CURRIE & HECHT ORAL AND MAXILLOFACIAL SURGEONS, P.C. and to CENTER FOR AMBULATORY ANESTHESIA, INCLUDING (herein known as “Providers”) for their services. This assignment will remain in...

effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by my insurance. I understand that my plan may not compensate my Providers for their anesthesia services and I will therefore be totally responsible for all charges, I hereby authorize the Providers, to whom I assign benefits, to release any information about me necessary to process their claim. In the event that this account must be assigned to collection, I agree to pay all costs, including reasonable attorney fees. In addition, I hereby grant alien to these Providers - against any settlement, claim judgment, or verdict I may receive as a result of my accident for the payment of the Provider's bills.(Signatures proved by physician, anesthesiologist and patient along with a witness on 3/02/2015)                                                                                                                          OUR FINANCIAL POLICY                                                                                                                               CURRIE & HECHT                                                                                                             ORAL AND MAXILLOFACIAL SURGEONS, P.C.We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy or your responsibility.                               PAYMENT OF SERVICES RENDERED ARE DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AND DISCOVER.                                                                                                                           Regarding InsuranceIf you have insurance, we will help you receive maximum benefits. Any insurance claim will only be completed if we are furnished full insurance company information. Otherwise, you are responsible for payment at time of service.INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. We will inform you if we are a party to your insurance contract and will handle your claims according to our agreement with the insurance company. We file insurance claims as a courtesy to our patients with those insurances we participate with, otherwise you are responsible for payment and we will, in turn, give you the necessary receipt for you to submit for reimbursement. If you have any questions regarding the payment allowance by . your insurance company, our insurance department will be happy to assist you. Please have your "Explanation of Benefits” on hand when you call our office. We will NOT become involved in the dispute between you and your insurance company regarding deductibles, copayments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary. YOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF YOUR ACCOUNT.THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICY. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNSI understand that I am financially responsible for all charges whether or not paid by my insurance. If I have not made any attempt to make payment or set up a payment schedule for my account, I understand that after my account is 90 days delinquent, I will be sent to a collection service and may be charged additional fees.Responsible Party Signature Date: (Consumer's signature provided on 03/02/2015)