Thank you for choosing the Thomas Johnson Surgery Center as your health care provider. The Center is committed to providing you quality care. Providing quality care depends on the Center being paid for the services that it provides. This form describes the Center’s Patient Financial Responsibility Policy. You must read and sign this Patient Financial Responsibility Policy before you receive treatment at the Center.
You must pay the Center your co-payment/co-insurance obligation before or on the day of your surgery. The Center accepts cash, checks and credit cards (Visa, Mastercard, or Discover). You are responsible for paying the balance of the Center’s fee after your surgery, which may be satisfied by either you or your insurance company paying the Center’s fee. The Center charges what is usual and customary for this area. You are responsible for paying the Center’s full charge, even if your insurance company pays a lesser amount based on its arbitrary determination of what constitutes usual and customary rates.
The Center does not have the authority to bill your insurance company unless you provide the Center the correct insurance information and assign your benefits under you insurance plan to the Center (in a separate form). Your insurance policy is a contract between you and your insurance company. The Center is not a party to that contract, and therefore, has no right to require the insurance company to pay it for the services that you receive at the Center.
If your insurance company does not pay your account in full within 90 days of your surgery, or if your insurance company issues a check directly to you to pay the account, the Center will bill you the balance of the account. If you do not pay the balance, the Center has the right to initiate collection proceedings against you. In that case, you will be responsible for not only the balance of your bill, but you will also be responsible for all the fees that the Center incurs in the process of collecting this amount, including collection agent fees, attorneys’ fees and court costs.
Proceed to Anesthesia Consent Form