Billing Consent Forms

Billing Consent

PATIENT INFORMATION

Full Legal First Name *

Full Legal Last Name *

Date of Birth *

Email Address *

Cell Phone *

Credit card on file policy
This form serves as confirmation that you are aware that Northstar Surgery Specialists P.A. has a policy that requires each patient to follow a payment plan with a credit card on file.

I hereby consent to follow the payment agreement given below with strict abidance. Should I have any difficulty, I fully accept it as my responsibility to report this matter to Northstar Surgery Specialists before my next payment, so as to allow for alternate arrangements to be made.

This policy is in effect due to the raise in patient deductibles and patient responsibility due to the change in health insurance policies and guidelines. If you have any questions about your coverage, please contact your insurance company on the number listed on the back of your insurance card.

If surgery is required, a cost estimation will be provided to you prior to surgery UPON REQUEST. Feel free to email your request to biller@northstarsurgery.com.

The benefit of this form is that no cost will be collected up front prior to surgery. By signing below, this allows us to set you up on a payment plan of $100/month for ANY AND ALL charges incurred from office visits and operations. If you decline to put your card on file, you will be responsible for paying your amount due in full PRIOR TO SERVICES, unless alternate payment arrangements have been agreed upon by the billing administrator of NorthStar Surgery Specialists,P.A.

I agree to the above policy with the below credit card. *

If I disagree, I acknowledge I will be responsible for full payment of any amount due. *

IF YOU AGREE - PLEASE PROVIDE A VALID CREDIT CARD BELOW:

Credit Card Number *

Exp Date *

CVV *

Zip Code *

We allow you to choose the day of the month that you want your card run on. Day of the month *

If you disagree, you WILL BE REQUIRED TO PAY FOR SURGERY IN FULL PRIOR TO THE SERVICE BEING PERFORMED.

Statement of billing practices
If I have questions, I understand that it is the patient's responsibility to obtain answers to their questions.

Patient will receive a total of 3 bills via mail to the address given on the patient registration form. If no payment is received, patient is subject to consideration for our external collection agency.

If an email is on file, we will attempt to send you a courtesy email when your account is at risk of being referred to our collection agency. We ask that upon receipt, you reach out to our office within 3 business days to arrange payment.

As a final attempt, we will attempt to reach out to you via phone once to the phone number listed on file, this FINAL attempt will be made 3-5 business days prior to your account being referred to collections.

We ask that payment be remitted to our office within 30 days of receipt of statement.

We offer courtesy flexible payment plans for balances due to help patients with the amounts due.

We also offer online payments for your convenience on our website: North star surgery

Date

Signature: *