1. I understand that my appointment may be rescheduled if I do not have proof of valid and current insurance, have not properly listed Dr. Swamy as my PCP if required, and / or I do not have the ability to pay my financial responsibility (co-payments, deductible or coinsurance rates) at the time of service.
2. I understand that Sunita Swamy MD PA will collect all copayments at the time of visit and any procedure deductibles and coinsurance up to an amount equal to payment in full for the planned procedure code. Expected deductible and coinsurance amounts are determined by the anticipated billing code(s), details of your insurance policy, and agreement between your insurance company and Sunita Swamy MD PA. Any overpayment to your account will be refunded to you at your request after payment and/or remittance has been received from your insurance company.
3. I understand that Sunita Swamy MD PA does not handle, accept, or file worker’s compensation claims.
4. I have read the Notice of Privacy Practices, explaining how my medical information may be used and disclosed. If requested, I am entitled to receive a copy of the Notice of Privacy Practices.
5. I understand that a $35 service fee will be added for any checks returned for any reason and I will be responsible for payment of this fee and the amount of the returned check. NSF checks must be redeemed with certified funds (cashier’s check, money order, or cash.)
6. I understand that if I am unable to make a scheduled appointment I need to contact Sunita Swamy MD PA at least 24 hours before my scheduled appointment time. Due to a high demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need of urgent care from being seen.
A $50 FEE MAY BE ASSESSED FOR ALL MISSED APPOINTMENTS & MISSED PROCEDURES NOT CANCELED WITH AT LEAST 24-HOUR ADVANCED NOTICE.
7. I understand that if my account is not paid in full within 90 days of a statement date, a 35% collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.
8. Should my insurance company request, it is my responsibility to provide my insurance company with the information needed to process a claim for services. It is also my responsibility to notify Sunita Swamy MD PA if there is any change in my insurance coverage, residence, or phone number. Ultimately, it is up to me to know my insurance benefits.
9. I understand that I am financially responsible for all fees and balances, including but not limited to those listed below, regardless of insurance coverage:
Medical Records Fee: Per the Texas Medical Board rules including Section 165.2, the fee for Medical Records starts at $25 and increases depending on the total number of pages.
Paperwork Processing Fees: There may be a fee for paperwork not exceeding $50, depending on the forms, information needed, and the time required to fill them out.
I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.
Assignment of Benefits
We require insured patients to complete an assignment of benefits authorizing insurances to remit payment to the physician’s office.
I hereby assign all medical and/or surgical benefits, to include major medical benefits, to which I am entitled, private insurance, and any other health plans to: Sunita Swamy MD PA. This assignment will remain in effect until revoked by me in writing. A photocopy or electronic copy of this assignment is to be considered as valid as an original.
I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all medical information necessary to secure the payment.
– Effective March 4, 2019