Get Patient Responsibility Form - Family Practice By The Lake

Filling out the Patient Responsibility Form is an essential step in understanding your financial obligations when seeking medical care at Family Practice By The Lake. This guide will help you navigate the online form easily and efficiently.

Follow the steps to complete your form seamlessly.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by reviewing the section titled 'Individual’s Financial Responsibility.' Here, you will acknowledge that you are financially responsible for any health insurance deductible, coinsurance, or non-covered services. Make sure to check the box confirming your understanding of this obligation.
3. Continue filling out the 'Individual’s Financial Responsibility' part by acknowledging the following points: Co-payments are due at the time of service, referrals need to be obtained if required by your insurance plan, and if your plan deems any service as 'not payable,' you accept responsibility for the full charge.
4. If you are uninsured, please indicate your agreement to pay for medical services during your visit in this section.
5. Proceed to the 'Insurance Authorization for Assignment of Benefits' section. Here, authorize Family Practice by the Lake to receive payment for the services rendered on your behalf by signing the corresponding area.
6. Next, complete the 'Authorization to Release Records' section, allowing Family Practice by the Lake to release necessary medical information to relevant parties for payment reconciliation and authorization purposes.
7. In the 'Medicare Request for Payment' section, if applicable, request Medicare benefits for the services provided by Family Practice by the Lake. Additionally, authorize the release of your medical information to Medicare for the determination of these benefits.
8. Once all sections are filled out, ensure you sign in the designated area for 'Signature of Patient, Authorized Representative or Responsible Party' and include the date of signing.
9. Finally, print or save the completed form. Depending on your needs, you can also download or share it once finished.

Complete your Patient Responsibility Form online today and ensure a smooth experience at Family Practice By The Lake.