I, the responsible party, certify that the above information is true and correct to the best of my knowledge.
I understand that I am financially responsible for all charges regardless of delays in insurance payment or denial of insurance coverage.
It is my responsibility to understand and have personally verified if my insurance is contracted with this practice and/or the doctor I am seeing.
I hereby authorize BASS Medical Group to apply for benefits and receive payments directly on my behalf for covered services rendered. They may also disclose any or all parts of my clinical record to any insurance company covering services for the purpose of satisfying charges billed.
I further agree to pay all collection costs, attorney fees and any other collection costs that may be incurred in the attempt to collect outstanding patient responsibility amounts.
I also understand, that if any insurance payments are sent directly to me, it is my responsibility to send
these monies directly to BASS Medical Group. immediately upon receipt.
I, the patient or the patient’s representative, understand that all medical doctors at BASS Medical Group are licensed and regulated by the Medical Board of California. I can verify this by contacting the Medical Board at (800) 633-2322 or via the internet at their website: www.mbc.ca.gov.