Financial Policy & Acknowledgement
Assignment of Insurance Benefits
Pa�ent Name: ___________________ Date of Birth: _____________ Medical Record #: ____________
FINANCIAL POLICY
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I agree I am financially responsible for and agree to pay VFMC for services, supplies and use of facili�es to
provide my medical care and understand VFMC will charge me at the applicable rate for each loca�on that
I receive medical care.
If I choose to have my health insurance reimburse VFMC for my medical care, I give permission to VFMC to
bill any such insurer and update that informa�on as necessary. I understand that insurance coverage varies
and that my insurer may not pay for everything or may pay only part of my bill. If my insurer has an
agreement with VFMC, then except for any applicable co-payments, coinsurance or deduc�bles, I will not
be responsible for charges over the rate my insurer and VFMC have agreed upon.
I understand that my insurer may deny payment for services that the insurer decides are not “medically
necessary” or that are “experimental.” While VFMC will take reasonable steps to appeal these denials, I
understand that I am responsible for paying for services denied by my insurer. If I choose to have VFMC bill
my health insurance to pay for my treatment, I assign to VFMC my rights to receive payment from my
health insurer or plan. I also appoint VFMC as my authorized representa�ve and grant VFMC limited
power of atorney to receive plan coverage informa�on and appeal any rights to payment and healthcare
benefits. I agree to cooperate and provide informa�on as needed by VFMC to establish my eligibility for
my insurance benefits.
In the event that a payment is not made when due, and con�nues unpaid for a period of ten (10) day
therea�er, I am responsible to pay VFMV in addi�on to all amounts of principal, a late charge of five cents
($0.05) for each one dollar ($1.00) overdue, or such lesser charge a may be required or permited by law,
but in no event shall the later charge be less than twenty five dollars ($25.00) for the purposes of
defraying expenses incident to handling the delinquent payment.
There is a service fee of $25.00 for all returned checks.
I will be mailed a billing statement that contains the total cost of service(s) or procedure(s) received from
VFMC. I can generally expect this billing statement within twenty (20) days a�er my insurance company
has responded to a submited claim. I am responsible for no�fying VFMC of any errors or objec�ons to the
billing statement within thirty (30) days or the billing statement will be deemed accurate, and the fees and
expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with
my account, it is my responsibility to contact VFMC to address the problem or to discuss a workable
solu�on.
If I have an outstanding balance for more than ninety (90) days, I may be referred to an outside collec�on
agency and charged a collec�on fee of 25% of the balance owed, or whatever amount is permited by
applicable state law, in addi�on to the balance owed. In addi�on, if I have unpaid delinquent accounts, I
may not be allowed to schedule any addi�onal services unless special arrangements have been made. If
your account is sent to our collec�on agency, you will be responsible for all fees incurred from the
collec�on agency.
Should collec�on proceedings or other legal ac�on become necessary to collect an overdue or delinquent
account, I understand that VFMC has the right to disclose to an outside collec�on agency or atorney all
relevant personal and account informa�on necessary to collect payment for services rendered. I am
responsible for all costs of collec�on including, but not limited to: (i) late fees and charges and interest due
as a result of such delinquency; (ii) all court costs and fees (but only to the extent allowed by law); and (iii)
a collec�on fee to be charged under separate agreement with a third-party collec�ons agency, either as a
flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable
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Financial Policy & Acknowledgement
Assignment of Insurance Benefits
Pa�ent Name: ___________________ Date of Birth: _____________ Medical Record #: ____________
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law, and to be added to the outstanding balance due and owing at the �me of the referral to the third
party collec�on agency. I acknowledge that any such interest assessed on the account will be a late fee as
a result of default or delinquency on my account, and is not deemed interest as part of a credit
transac�on. If my account is referred to a collec�on agency, atorney, court, or the past due status is
reported to a credit repor�ng agency, it may have an adverse effect on my credit history; and related
por�ons of my account, including the fact that I received treatment at VFMC, may become a mater of
public record. Failure to comply with any of these policies may also result in a Credit Withdrawal of Care.
By signing this agreement below, I agree, on behalf of myself, my legal representa�ves and next of kin, that
the jurisdic�on, venue, and choice of law of any dispute or state court ac�on related to the health care
services or the billing provided by VFMC shall, at the op�on of Medical Associates, be subject to the
exclusive jurisdic�on of the Commonwealth of Pennsylvania.
As required by the Fair Pa�ent Billing Act, I understand:
o I may receive separate bills from VFMC providers for the services provided to me.
o All providers may not par�cipate in the same insurance plans and networks. Services provided by
non-par�cipa�ng providers in an insurance plan or network are defined as “out-of-network
services.” I understand that I may have greater financial responsibility for out-of-network services.
o I understand that it is my responsibility to contact my insurance company to determine whether
VFMC is a par�cipa�ng provider in my insurance plan or network.
o Any ques�ons I have regarding my health insurance coverage or benefit levels should be directed
to my health plan, my employer or my insurance cer�ficate of coverage. VFMC cannot guarantee
that a service will be covered under my plan.
CREDIT CARD ON FILE
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By my signature below, I authorize VFMC to securely store my credit card informa�on and only charge it
should I have an outstanding balance or any le�over balance from a processed claim in the future. I am
aware that the storage system used is fully compliant to the highest level of credit card storage security
regula�ons. Once stored, I am aware that only the last 5 digits of my card are viewable by VFMC
personnel. I understand that I am responsible for all charges for services that I receive from VFMC, and
that if the pa�ent responsibility por�on of my charges (including charges applied to my deduc�ble and/or
coinsurance) is not paid in full within thirty (30) days following the receipt of the pa�ent financial
responsibility statement mailed from the VFMC Billing Office, VFMC will bill my stored credit card for the
outstanding balance due.
AUTHORIZATION TO RECEIVE PAYMENT AND BILLING
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I request Valley Forge Medical Center and/or its affiliates to submit claims on my behalf to my insurance
company or other third party payor for my care and authorize disclosure of health informa�on to the
extent necessary to obtain payment for the hospital and/or physician services.
In considera�on of the health care services provided to the pa�ent, I assign and authorize my insurance
company or other third party payor to make payments directly to VFMC including charges for physician
services.
In considera�on of the health care services provided to the pa�ent, I assign to VFMC any medical benefits
to which I may be en�tled to receive, including without limita�on any such benefits due or claims I have
under or pursuant to a health care employee benefit plan, governed under ERISA, 29 U.S. Code § sec. 101
et seq.
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Financial Policy & Acknowledgement
Assignment of Insurance Benefits
Pa�ent Name: ___________________ Date of Birth: _____________ Medical Record #: ____________
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I have been informed that:
o I must pay all charges, co-payments, deduc�bles, and coinsurance not covered by my insurance
company, Medicare, or third party payor.
o I must pay all charges incurred if I lack insurance coverage and will also contact VFMC to work
with them to iden�fy financial op�ons available for me.
o Failure to sign this authoriza�on may result in denial of payment.
o I agree to pay for non-covered services or services not covered as a result of my failure to obtain
pre-authoriza�on for treatment as required by any such payor, or agreed upon services deemed
as medically unnecessary by the payor.
o VFMC will use good faith efforts to protect pa�ent’s right to confiden�ality in appropriately
providing health informa�on to payors, including review for ac�ve coverage not previously
communicated to VFMC in order to seek payment on behalf of the pa�ent.
I understand that informa�on disclosed as a result of this authoriza�on/consent may no longer be
protected and could poten�ally be redisclosed. However, such disclosure must be consistent with other
State and Federal Law (42CFR Part 2), which prohibits the recipient from making any further disclosures
without specific writen consent of the person to whom the informa�on pertains. I understand that I am
under no obliga�on to sign this authoriza�on/consent and that my treatment will not be dependent on
such. I may revoke this authoriza�on/consent at any �me with writen or verbal no�ce to Valley Forge
Medical Center and Hospital, except as to informa�on already released in reliance on this
authoriza�on/consent
I authorize my insurance company, responsible for payment of my medical care and treatment, to pay
VFMC for the services given. I understand that I am responsible for any charges not covered by insurance.
I agree that if my account is not paid when due, VFMC may retain a lawyer and/or collec�on agency for
collec�on. I will be responsible to reimburse VMFC for all costs, charges, and fees associated with the
collec�on of the amount due. This includes, but not limited to, reasonable inters, legal cost in the event
suit is filed and reasonable lawyer fees and/or reasonable collec�on agency fees including those based on
a percentage of the debt.
If I do not want VFMC to bill my insurance, I must no�fy them at the �me of service.
ASSIGNMENT OF BENEFITS
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I hereby assign to the prac�ce any insurance or other third-party benefits available for health care services
provided to me. I understand the prac�ce has the right to refuse or accept assignment of such benefits. If
these benefits are not assigned to the prac�ce, I agree to forward all health insurance or third-party
payments that I receive for services rendered to me immediately upon receipt.
I assign VFMC:
o All benefits, claims, and any and all other rights, including my right to bill and talk to any third
party for the purposes of seeking payment, regarding my charges at VFMC.
o The right to file suit or intervene in any lawsuit or proceeding which involves my charges at VFMC
o The right to take any other ac�on to seek payment of my charges at VFMC
This assignment includes, but is not limited to, the right to appeal the denial of payment of my VFMC
charges from any payer, including any employee-sponsored benefit plan, insurance policy or insurance
coverage provided by law or contract.
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Financial Policy & Acknowledgement
Assignment of Insurance Benefits
Pa�ent Name: ___________________ Date of Birth: _____________ Medical Record #: ____________
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I also assign to VFMC, and agree that I waive, any and all rights to setle, release or retain payment of my
VFMC charges, or take any other ac�on which would in any way compromise payment or reimbursement
of my VFMC charges.
I also appointment VFMC as my authorized representa�ve for the purposes of pursuing payment for my
VFMC charges. I authorize VFMC to act on my behalf to purpose any benefit claim, including one number
Employee Re�rement Income Security Act of 1974, and to appeal an adverse benefit determina�on. I
agree to assist VFMC in the pursuit of all insurance benefits and agree to pay all co-insurance, copayments and deduc�bles required by any insurance plan.
I authorize and direct VFMC to apply the proceeds of any recovery to my VFMC charges.
MEDICARE PATIENT CERTIFICATION AND ASSIGNMENT OF BENEFIT
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I cer�fy that any informa�on I provide, if any, in applying for payment under Title XVIII (“Medicare”) or
Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be
made on my behalf to VFMC by the Medicare or Medicaid program.
If I claim benefits under Title XVIII of the Social Security Act (Medicare), I hereby cer�fy that the
informa�on I provide in applying for payment of such benefits is correct, and I authorize VFMC to release
to the Social Security Administra�on, its intermediaries or carriers any informa�on needed for this or any
related Medicare claim. Even though I may assign my right to receive payment from my insurer, I
understand and agree that VFMC may s�ll require payment directly from me.
ACKNOWLEDGEMENT
I have read, understand and agree to the tenants of the consent in this form. I have been given the opportunity to
ask ques�ons and I have no remaining ques�ons at this �me. I understand where I can access addi�onal
informa�on. I cer�fy that to the best of my knowledge and belief the informa�on provided is complete and correct.
In understand that this consent subject to revoca�on by me at any �me except if the person or en�ty authorized to
make a disclosure has already acted in reliance on the form. This consent expires one year from the date of signing.
I hereby acknowledge that I have read, understand, and agree to the following and that I have been
given the opportunity to ask ques�ons:
Financial Policy
Assignment of Health Insurance Benefits
A copy of this consent form as been offered to me:
Accepted
Pa�ent Signature
Date
Witness Signature
Date
Declined
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