INSURANCE

IF AUTO OR WORK COMP:

IF WORK COMP:

IF PERSONAL MEDICAL INSURANCE:

Financial Policy-I understand and agree that my insurance policies are an arrangement between the insurance company and myself. The clinic, as a courtesy to you, will bill your insurance company. I authorize my insurance company to pay the Eisman Clinic, P.C. directly. All monies paid will be applied to my account. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will be immediately due and payable. Some plans may not cover the entire bill or may refuse to pay. You will be responsible to pay any unpaid balance. If you do not have insurance, then all services are paid per visit or in advance. Please speak to the doctor about payment/family plans. I authorize the Eisman Clinic, P.C. to release all records as needed for collecting bills for services that I may or will incur. Records may be sent via mail or electronically (fax or email) as deemed by the eisman clinic. I understand and agree to the financial policies of the Eisman Clinic, P.C.

Signature

Date