Consent to Treatment and Financial Responsibility

You hereby and voluntarily consent to authorize Brookside Women’s Medical Center’s healthcare providers, including its physicians and midlevel providers (Physician Assistants, Advance Practice Nurses) at their service locations to provide you health care services.

You consent to the medical/surgical procedure(s) and treatment(s), including but not limited to anesthesia, laboratory procedures, x-ray examinations and physical therapy to be rendered pursuant to the general and special instructions of your physicians.

You are legally responsible for all charges in connection with the medical care and treatment provided by representatives of Brookside Women’s Medical Center.

If you have insurance, you assign the insurance benefits to Brookside Women’s Medical Center and authorize and direct your insurance carrier to pay those benefits directly to Brookside Women’s Medical Center.

You understand your insurance carrier may not approve or reimburse medical services in full due to usual and customary rates, benefit exclusions, coverage limits, and lack of authorization or medical necessity. Furthermore, you are responsible for fees not paid in full, co-payments, policy deductibles and co-insurance except when your liability is limited by contract State or Federal law.

Your insurance policy has a contract between you, your employer and the insurance company. OUR RELATIONSHIP IS WITH YOU, NOT YOUR INSURANCE COMPANY. We provide a quote of benefits and claims submission as a courtesy to our patients but this does not guarantee that your insurance will pay for the services you receive.

ALL CHARGES ARE YOUR RESPONSIBILITY WHETHER YOUR INSURANCE COMPANY PAYS OR NOT. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We try our best to prepare you for what your financial responsibility will be but ultimately it is up to you to be familiar with your plan and benefits.

Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.

If Tricare, Medicare, Medicaid, or similar government program should determine that you are not eligible for coverage or that the service or treatment is not covered, you will be responsible for payment, unless prohibited by law.

Payment is expected at the time of service, accounts that are more than 120 days past due will be sent to a third party collection agency. We require full payment before scheduling the following procedures: Endometrial Biopsy, Dilation & Curettage, Colposcopy, Leep Cone, Essure, Novasure, and Hospital Surgeries. You may pay by Visa, MasterCard, Discover, American Express, Cash or Money Order, and online through our patient portal. We accept checks for certain services only. Please make checks payable to: Brookside Women Medical Center. $25.00 charge on all returned checks.

We have an afterhours answering service set up to take calls from patients that are experiencing an emergency. If you are not having an emergency, please wait to contact our office during normal business hours.

Thank you so much for all your help. Everyone has been so friendly, supportive, and compassionate. I?m so thankful for this facility. I don?t know what I would have done without you.
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