Financial Statement & Authorizations


It is the policy of this practice that payment in full is due at the time services are rendered.  We are happy to accept your payment by check, cash, Visa, MasterCard, Discover, or American Express.  We will submit claims to those insurance companies with whom we have a contract; however, it is the sole responsibility of the insured to know the type of insurance, assigned primary care physician, and copays or deductibles.  All other patients will be given receipts that will be sufficient to submit to an insurance company for reimbursement.   All co-pays, deductibles, and coinsurances are due at the time services are rendered.  In the event, you are not prepared to pay at the time of service you may be asked to reschedule if your needs are not medically urgent.  Any balances that are over 90 days past due will be turned over to a collection agency unless previous arrangements have been made. 


Your Signature Will Serve for All of the Following


Consent:  I hereby give consent to Hope Centers of Central Florida to provide the necessary treatments discussed.  I have been offered a copy of the Privacy Policies for Hope Centers of Central Florida and authorized use/disclosure of information to coordinate and/or manage my healthcare and any related services, receive payment for services, and perform general healthcare operations including receiving email notices regarding practice services and appointment reminders via text, phone call and/or email. 


Medical Release:  I authorize any holder of medical or other documentation about me to release to Hope Centers of Central Florida, independent laboratories, and insurance carriers any information needed for claims processing & payments.  I permit a copy of this authorization to be used in place of the original.


Insurance Assignment:  I authorize payment of medical benefits to the attending physician/practice for services.


Financial Responsibility:  I understand that I am ultimately responsible for all charges incurred.  It is my responsibility to provide the office with all necessary information to file insurance claims and to notify the office of changes in coverage prior to any visits.  I understand that it is my responsibility to know my insurance coverage and benefits, including contracted laboratories/hospitals where I may receive care.  I will be responsible for any charges not covered by my insurance policy, including a $50.00 fee for “no show” appointments, special documents I request to be completed, or telephone consultations, all of which I acknowledge are not billable to insurance.  Additionally, I understand that I will be charged fees for medical record copies as per the Florida statute allowance.  I understand the above financial statement of timely payment.  I understand that any returned checks may be re-deposited electronically, including all fees assessed.