Patient Financial Responsibility Disclosure Statement
This document outlines the financial responsibilities of patients at Digestive Health Associates. It provides important information regarding payment obligations, insurance billing, and collection policies. Patients and responsible parties must understand and comply with these terms before receiving medical services.
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How do I fill this out?
To fill out this form, you will need to provide your personal information and details regarding your medical insurance. Ensure that all information is accurate and current before signing. It is essential to understand the responsibilities outlined in the statement.
How to fill out the Patient Financial Responsibility Disclosure Statement?
1
Read the entire document carefully before filling it out.
2
Complete all required fields with accurate information.
3
Present your insurance information for verification.
4
Sign and date the document.
5
Keep a copy for your records.
Who needs the Patient Financial Responsibility Disclosure Statement?
1
New patients at Digestive Health Associates who are visiting for the first time.
2
Parents or guardians of minors who need to ensure financial responsibilities are understood.
3
Responsible parties for patients who wish to clarify their payment obligations.
4
Individuals seeking treatment and need to understand their insurance policy coverage.
5
Patients who have had services rendered and need to acknowledge their payment responsibilities.
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What are the instructions for submitting this form?
To submit this form, please return it to Digestive Health Associates at either of the office locations: 18400 Katy Frwy. Ste. 440, Houston, TX 77094 or 915 Gessner Rd. Ste. 650, Houston, TX 77024. You can also fax it to (713) 468-1940 or email it to our office at contact@dha.com. Ensure that you keep a copy for your records after submission.
What are the important dates for this form in 2024 and 2025?
No specific important dates are applicable for this form in 2024 and 2025, but patients are encouraged to complete it prior to receiving services.
What is the purpose of this form?
The purpose of this form is to clearly outline the financial obligations of patients and responsible parties at Digestive Health Associates. It serves to inform individuals about their payment responsibilities associated with medical services and the processes for dealing with insurance companies. By signing this document, patients acknowledge their understanding of these obligations and agree to comply with them.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Name of the patient receiving medical services.
- 2. Responsible Party Name: Name of the person financially responsible for the patient.
- 3. Patient Signature: Signature of the patient indicating agreement.
- 4. Responsible Party Signature: Signature of the responsible party indicating acceptance of terms.
- 5. Date: Date when the form is signed.
What happens if I fail to submit this form?
If you fail to submit this form, you may experience delays in receiving timely medical services. Additionally, there may be consequences regarding financial responsibility that could affect your care. It is critical to comply with submission requirements to avoid complications.
- Delayed Services: Without submission, processing of medical services may be delayed.
- Increased Financial Liability: Not acknowledging your responsibilities can lead to unexpected costs.
- Inadequate Insurance Processing: Your insurance might not cover services rendered if this form is not submitted.
How do I know when to use this form?
- 1. First-time Patient Registration: New patients must complete this form to register for services.
- 2. Insurance Verification: Use this form to provide your current insurance details for billing purposes.
- 3. Updating Financial Responsibility: If there is a change in financial responsibility, this form must be updated accordingly.
Frequently Asked Question
What is this document for?
This document outlines your financial responsibilities as a patient or responsible party at Digestive Health Associates.
How do I fill out this form?
Provide your information accurately in the required fields and ensure you understand the terms before signing.
Can I edit this PDF?
Yes, you can easily edit the PDF using our user-friendly editor.
How do I download the edited PDF?
After making your edits, simply click the download button to save the document.
Is there a fee for submitting this form?
No, this form is free to fill out and submit.
Who should sign this document?
The patient or their responsible party should sign the document to acknowledge their financial responsibilities.
What if I don’t have insurance?
You will still need to complete this form and acknowledge your financial responsibilities.
Can I share this document?
Yes, you can easily share the PDF using the available sharing options.
What happens if I don’t submit this form?
Failure to submit this form may result in delays in receiving medical services.
Where can I get assistance with this form?
You can contact Digestive Health Associates for help with filling out this form.
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