You will need to sign that you have read the following policies and for the insurance assignment when you come in for your office visit.
 

POLICY OF THIS OFFICE:

  1. All first time visits must be paid for unless you can provide proof from your insurance company showingthat your deductible has been met.
  2. Co-payments must be paid at the time of visit.
  3. If we are not a contracted provider for your insurance company, you will be expected to pay 30% of thetotal charges if your deductible has been met.
  4. Medicare patients will be expected to pay 20% of the allowable charge if they do not carrysupplemental insurance.
  5. Insurance forms are the patient's responsibility to obtain and submit to us completely filled out and signed.If you do not have an insurance form to obtain reimbursement, reimbursement is then paid directly to you.
  6. A surgery deposit and an assignment of insurance are required prior to admission to the hospital andday-surgery.
  7. Dr. Lubritz is an investor in Universal Health Service, Humana, Sierra Health, Medical Care International,Las VegasSurgicalCenter, Sahara and Flamingo surgical centers.
 
 

INSURANCE ASSIGNMENT AND MEDICAL RECORDS RELEASE:

I, the undersigned do hereby authorize my insurance carrier(s) to pay directly to ___________________________ the insurance benefits, if any,otherwise payable to me for service rendered. I understand that I am financially responsible for any charges not covered by said insurancecarrier(s), including co-pay and deductible amounts. If for any reason the said insurance carrier(s) has not paid within 60 days from thedate of service rendered, the amount must be paid in full by me. Should this amount become delinquent, I will be responsible for all costsof collection. After 90 days from the date of service rendered, an interest charge of 1½% monthly, 18% annually, will be automaticallycharged to any unpaid patient balance. I, the undersigned, to hereby also give my permission to ____________________________ to furnish myinsurance carrier(s), also the above named referring doctor, any and all information pertaining to my medical records.