I hereby assign all rights, title, and interest of my primary and secondary insurance to Philip Malinas M.D. & Associates for the treatment of my medical services.
Payment methods include cash, check and credit card. Payment plans can be arranged in advance.
Insurance Reimbursement: In the event you receive reimbursement from your insurance company for services rendered by Philip Malinas M.D. & Associates, that payment is due and payable to our office and should be immediately forwarded to us.
Insurance Deductible: Deductibles or co-pay’s are to be paid in full prior to services being rendered.
If you do not have insurance payment is due in full at the time of service.
Fee for returned checks: The fee for returned checks is $30. The fee may be added to your account and payment is required in full by cash or credit card.
Records requests: All records requests will need to be on a signed form. These records are available to the patient with a charge of .60 cents per page and require a minimum of 3 business days to be processed.
I authorize treatment of the patient named above and agree to pay all fees and charges promptly upon presentation thereof, unless credit arrangements are agreed upon in writing. In the event legal action should become necessary to collect on an unpaid balance due for psychiatric services rendered I agree to pay reasonable attorneys fees or other such costs as the court determines to be proper. If covered by an HMO, I understand that I cannot be seen until the required authorization has been obtained. I also agree to pay all expenses that are not authorized or covered by my HMO. It is agreed that payments will not be delayed or withheld because of any insurance coverage issues or pending claims, and that all proceeds of insurance are assigned to this office where applicable. A copy of this assignment is as valid as the original.