Medicare will only pay for services that it determines to be reasonable and necessary under 1862(a)(1) of the Medicare law. If Medicare determines that a particular service is not “reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service.
If you are HMO patient, please enter the HMO details below.
I irrevocably authorize my insurance benefits to be payable directly to Dr. Yunus and/or the attending physician on my behalf. I understand that I am responsible for all co-insurance and non-covered charges. I understand that payment is due in full at time of service and if not I am responsible to make the appropriate financial arrangements. I consent to the release of information from my medical record as necessary for the collection of services being rendered by this establishment. I also understand that I am responsible for the payment of reasonable attorney fees and collection expenses if required for the collection of the account.
The use or disclosure of this information will be made by the medical office staff. The practice is hereby authorized to make the disclosure of this information to these classes of persons. I understand that I have the right to recoke this authorization, in writing, at any time by sending such written notification to above noted person. I understand that a revocation is not effective to the extent that the practice has relied on this authorization in it's actions. Also, a revocation is not effective if this authorization was obtained as a condition of abstaining insurance coverage, as other law provides the insurer with the right to request a claim under the policy or the policy itself. I understand that information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient and may no longer be protected by the federal HIPPA privacy regulations. The practice will not condition my treatment, payment, enrolment in a health plan or eligibility for benefits on whether I provide authorization of the requested use or disclosure of information.
This authorization is in force and effective for one year from date below.