If retired, please put retired/date of retirement. If student, please put name of school/part or full time.
(If retired, please put retired/date of retirement)
Responsible Party (If other than patient please fill in below):
Please note that we now require a copy of your Medicare, Medicaid and or Insurance Card to verify the mailing address, phone number and the spelling of your name as shown on each individual card. We can not file insurance claimes for you without the birthdate and social security number of the policy holder.
We are also requiring a copy of your driver’s license or other picture id that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.
We appreciate your help and understanding of these requests.
Primary Insurance Information:
Supplemental Insurance Information:
- By accepting the medical services provided to me by James A. Anderson, MD, Todd H. Beckstead, MD, Brock A. Anderson, MD, Darren Bowe, MD, and/or Kevin Helling, MD or any other employee of the corporation, I agree to be financially responsible for the charges billed by Wyoming Surgical Associates, P.C. for those services.
- If there is medical insurance which will cover all or a portion of the charges I incur by James A. Anderson, MD, Todd H. Beckstead, MD, Brock A. Anderson, MD, Darren Bowe, MD, and/or Kevin Helling, MD or any other employee of the corporation for my treatment, I hereby assign those insurance benefits to Wyoming Surgical Associates, P.C., and authorize the insurance benefits to be paid directly to Wyoming Surgical Associates, PC. This assignment will remain in effect until revoked by me in writing.
- I understand and agree that if my insurance benefits do not cover all of the charges for my treatment, including what my insurance company classifies as over reasonable and customary charges, that I am responsible to pay any outstanding balances. I further agree that in the event of non-payment to Wyoming Surgical Associates, PC of any amounts due under this agreement I will pay interest thereon at the rate of 1.75% per month and pay all of Wyoming Surgical Associates, PC reasonable legal fees, attorney fees and court costs that may be incurred. I agree that in the event this agreement is assigned to a collection agency for collection I promise to pay a collection fee of 35% of the unpaid balance due which is in addition to the unpaid balance due under this agreement.
- I understand that it may be necessary for Wyoming Surgical Associates, P.C. to disclose medical information about my treatment to my insurance companies, employer, or third-party payers in order to process a claim on my behalf.
- A photocopy of this assignment and financial agreement is to be considered as valid as the original.
- I understand that it is my responsibility to contact my insurance company for pre-authorization on procedures.
I hereby give my permission for any employee of Wyoming Surgical Associates, PC as well as any physician’s office or facility to which I may be referred to contact me at:
- My work phone
- My work phone and leave a message to call back
- My home phone and leave a message to call back
- My home phone and leave a detailed message on either an answering machine or with whoever answers the phone.
- Any other verbal or written contact I have provided to your office for both call back and detailed messages.