Patient Acknowledgement of Financial Responsibility

- The patient (patient’s guardian, if a minor) is ultimately responsible for the payment of treatment and care.

-We will attempt to confirm your insurance coverage prior to your treatment.  However, your benefits are a contract between you and your insurance company.  As a courtesy, Manchester Care Clinic  will attempt to file for payment from your insurance company.

-It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.

-Patients are personally responsible for knowing and understanding their own insurance policy, including co-payment, deductible, eligibility, and coverage.  If you have questions regarding your coverage, please call your insurance company directly.

-Verification of coverage is not a guarantee of coverage or payment. Actual benefits are determined by your insurance company upon receipt of the claim.

-Laboratory services are provided by AEL Laboratories/Access Labs/ Gravity Diagnostics. There may be additional charges for labs performed. Any questions about billing from the Lab provider are to be resolved by contacting the lab company directly.

-If deductibles apply, you will be expected to make a $75 deposit at the time of service or pay the copay listed on your benefits card..  We will bill any remaining deductible determined by your insurance company to you. 

-Medicare Patient Certification and Assignment of Benefit. I certify that any information I provide, if any, in applying for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to Manchester Care Clinic LLC  by the Medicare or Medicaid program.

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