Patient Financial Responsibility
Agreement

A. Financial Responsibility. In consideration of CIFE providing me with health care services, I agree as follows:

1.  I will be responsible, either personally (for services not covered by my insurance) or through my insurance coverage, for payment to CIFE for all services provided to me by CIFE.
2.  I hereby assign payment by any third party, including private insurance and credit card companies, for all services provided to me by CIFE, directly to CIFE. I understand and agree that I remain liable for all charges and/or applicable co-payments, co-insurance and deductibles not covered by this assignment.
3.  For services not covered by my insurance, I agree to pay CIFE within seven (7) days of the date of any invoice.
4.  I understand that after 30 days of non-payment of any CIFE invoice that CIFE may, in its sole discretion, stop providing services to me.
5.  If my current insurance policy prohibits direct payment to CIFE, I hereby authorize and instruct my insurance carrier to mail directly to CIFE any check for any payment of benefits due to me.
   1.  Immediately upon CIFE’s request, I will endorse such payment(s) over to CIFE.
   2. This is a direct assignment of my rights and benefits under my insurance policy.
   3. Any payment made pursuant to this assignment will not exceed my indebtedness to CIFE but I hereby agree to pay, in a current manner, any balance due to CIFE over and above any insurance benefit payment received by CIFE.
   4. For purposes of carrying out the provisions of this assignment, a photocopy of this Agreement shall be treated as an original.
   5. I hereby authorize CIFE to initiate, on my behalf, any action it deems necessary to enforce the provisions of this assignment of benefits, including, but not limited to submitting a complaint to the appropriate Insurance Commissioner.
6. If I receive any payment of insurance benefits for services provided to me by CIFE, I will immediately forward any and all such monies, along with the explanation of benefits, to CIFE.
7.  I will notify CIFE immediately upon my dis-enrollment from my current insurance carrier or any other change of benefit that could affect payment to CIFE for its services.
8.  I acknowledge that it is not the insurance company’s responsibility to inform CIFE of any change in my coverage, and the insurance company will not pay for non-covered services or for services I receive after I am no longer covered.
9.  I understand that I will be held liable for payment if I fail to notify CIFE if I dis-enroll from or become ineligible for coverage under my current payer(s).
10.  CIFE will charge, and I agree to pay, a 1.5% monthly finance fee on all outstanding balances over 30 days and, if necessary, collection and attorney’s fees.
11.  I must provide at least 24 hours’ advance notice of cancellation of any appointment by calling 954-538-0022 or such other number as CIFE mandates. CIFE may charge me a $50 cancellation fee if I do not cancel in a timely manner as required by this Agreement.
12.  I also agree to pay CIFE $30.00 for any checks returned unpaid for any reason.

B. Release of Information. I authorize:

1. any health care insurer with whom I have or may have coverage to disclose to CIFE any information regarding my coverage and any payments made directly or indirectly for services rendered to me by CIFE;
2. any credit card company to which I charge fees for services provided to me by CIFE to disclose to CIFE any information regarding my account and any fees charged for services rendered to me by CIFA;
3. CIFE and its designees, to release to any public or private regulatory entity, accrediting entities and to any third party insurer or other person or entity which provides insurance on my behalf or for my benefit, information concerning my medical history, condition, lab and test results;
4. CIFE and its designees, to conduct any credit and financial history check, inquiry or information gathering activities it feels, in its sole discretion, is or are necessary to verify my ability to pay for products or services provided by CIFE.
    

I hereby release CIFE, its designees and any person or entity providing information as contemplated above from any and all liability in connection therewith.

I have read and understand the provisions of this Agreement, I have had a chance to ask questions about the Agreement and I agree and acknowledge that I am financially responsible for services received from CIFE. I acknowledge that this Agreement binds me and my heirs, executors, administrators and assigns. I am signing this Agreement of my own volition with full understanding of its meaning.