Here is a copy of our standard financial agreement for reference:
I request that payment of authorized benefits payable by any federal or state health care program or commercial payer be made either to me or on my behalf to Advanced Orthopaedics & Sports Medicine, PC for any services furnished to be by its physicians or employee at any location. I authorize Advanced Orthopaedics & Sports Medicine PC to release its billing agents, The Health Care Financing Administration, and my insurer as applicable, any information (including but not limited to information regarding drug and alcohol program participation, diagnosis, prognosis, treatment, or referral) needed to determine these benefits, the benefits payable for related services or to obtain payment for services provided. I understand that I may revoke this consent to the release at anytime, except to the extent relied upon by Advanced Orthopaedics & Sports Medicine, PC or the disclosure is authorized by law. This consent to the release of payment information remains valid until expressingly revoked by me in writing. I understand that I am primarily financially responsible for the payment of any services provided.