Assignment & Release.pdf

Ardent Care/Dr. Renee Watts requires patients to understand and agree to their financial agreement, which includes being responsible for payment of services rendered, with insurance billed as a courtesy. Patients are responsible for deductibles, co-payments, and non-covered services. Estimated payments or co-payments are due at the time of service, unless other arrangements are made. Unpaid balances after 60 days will be subject to a 1.5% monthly late fee charge. Delinquent accounts may be forwarded to a collection agency after 90 days. Patients assign their insurance benefits to Dr. Watts and are responsible for remembering their appointments, with a 2-day notice required for cancellations. The office has a reminder system, but patients are still responsible for remembering their appointments. Patients authorize Dr. Watts to furnish their insurance company with required information to process claims and consent to the making of photographs, study models, and X-rays. Patients acknowledge receipt of the Notice of Privacy Practices.