I accept full financial responsibility for medical expenses incurred at the South Coast Neurology, Inc.
I understand that I am responsible for the following possible charges
It is my responsibility to inform South Coast Neurology, Inc. if I am working with a third party payer in reference to my condition i.e. workers’ compensation and legal counsel. Failure to do so prior to service being rendered will cause all costs associated with my care to be my personal responsibility.
If claims filed by South Coast Neurology, Inc. to my insurance company or any other third party are denied, I will cooperate with the billing department of South Coast Neurology, Inc. to ensure payment for my services. I understand that I will be legally responsible for all costs associated with the collection of my account, including collection fees, if I default on this agreement.
I authorize South Coast Neurology, Inc. to charge co-insurance, no-show fees, outstanding balances, and/or any charge
for services rendered at 1919 State Street #203 Santa Barbara CA 93101
In our efforts to improve patient service and office efficiency, we have implemented a policy which enables you
to maintain your credit card information securely on file with South Coast Neurology, Inc. In providing us with your credit
card information and signing this form, you are giving SCN, permission to automatically charge your credit card on file for
your deductible, co-insurance, no-show fee, or outstanding patient balance TWO WEEKS after insurance has adjudicated
your claim. As a courtesy, you will be sent a billing statement when a balance becomes due.
What if I have a debit card or HSA? How will I know exactly when the charge will be put through?
You are notified by your insurance company of any patient portion due by you. We also send you a statement after which you have TWO WEEKS to review and pay your balance with your preferred payment. If we do not hear from you within the two weeks, we assume you are in agreement with your balance and prefer we use your credit card on file. If you would like a credit card receipt, you are welcome to call our office and request it within 60 days of the charge.
This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment. We recommend you contact your insurance company first with any insurance discrepancies
CHARGEBACK CARD: Any card that a chargeback is initiated without the consent of South Coast Neurology, Inc is subject to a $40.00 fee, regardless of the balance as well as late fees that apply to an overdue balance. Primary Insurance and Plan Insurance Address should not be required to sign.
It is my responsibility to make sure the card on file is valid and accurate. I will notify South Coast Neurology as soon as possible with any card information changes. In the event that there are any problems with my credit card payment, I agree to pay all collection costs and reasonable attorney’s fees incurred in attempting to collect on the account balance
I certify that this is my credit card and that I am legally authorized to give permission for its use by South Coast Neurology, Inc for my balances on my account.