Benefits & billing

Preauthorization for care and the acquisition of a primary care referral for services/devices are the responsibility of the patient and are not a guarantee of payment or benefits. Whether or not your insurance company pays in full, a portion or no portion of your medical bills is a matter between you and your insurance carrier. As a courtesy to our patients, it is our policy to submit charges directly to the patient’s insurance company, with the understanding that the patient is financially responsible for any medical services not covered by their plan. By signing this form, you assume financial responsibility for all non-covered services and visits for which (if necessary) you did not provide an appropriate referral. Failure to provide us with a valid referral at the time of services rendered constitutes a request for out-of-network services, cash-pay services or both.

I hereby authorize Balance and Hearing Resource Centers Inc. to apply for benefits on my behalf for medical services rendered. I certify that the information I have reported with regard to my medical insurance coverage is correct and further authorize the release of any necessary information, including medical information, for this or any other claim to my health insurance company. I permit a copy of this authorization to be used in place of the original.

I agree to sign this form electronically. Typing my name below is my signature, with the same effect as signing the paper form.