PATIENT AGREEMENT
Po Box 421607 Atlanta, GA 30342
PHONE: 770-559-8725
FAX: 770-559-8276
contact@primesurgicalassociates.com

This agreement is to inform you, the patient, that your surgeon has deemed that a surgical assistant is medically necessary to efficiently operate and to successfully complete your surgical procedure. Please note that the surgical assistant is NOT an employee of your physician, but is an employee of Prime Surgical Associates (herein stated as PSA). PSA will file a medical claim to your insurance company for services rendered by the surgical assistant. However, not all insurance companies will cover a surgical assistant. Therefore, please be aware of the following conditions:

1. If your claim is denied by your insurance carrier due to your deductible not being met PSA will bill the patient directly.

2. If your insurance carrier denies your claim based on non-covered services PSA will bill the patient directly.

3. If your insurance carrier denies your claim based on non-participating or out-of-network PSA will bill patient directly.

4. PSA is not a Medicare/Medicaid/Wellcare provider.

5. Cosmetic and elective procedures will be billed via fee scheduled provided.

Any remaining allowable amount (co-insurance/copay) will be billed directly to the patient. Any payments made from a Health Savings Account directly to PSA will be accepted as an insurance payment and this agreement will become null. This agreement is to authorize the release of any and all medical information to PSA that is necessary to process your medical claim(s), to assign medical benefits to PSA for surgical assisting services rendered, to appeal any and all denial of benefits for your procedure(s) and to understand that even though you have assigned insurance benefits to PSA it does not relieve you of your obligation to pay PSA if the conditions listed above apply.
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