Surgical Specialty Group of Oviedo
PATIENT NAME_________________________________________DATE OF BIRTH____________
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PATIENT FINANCIAL AGREEMENT
____________(Patient or Guardian Initials)
Financial Agreement.
I acknowledge, that as a courtesy, Surgical Specialty Group of Oviedo may bill my insurance company for
services provided to me.
I agree to pay for services that are not covered or covered charges not paid in full including, but not limited
to any co‐payment, co‐insurance and/or deductible, or charg es not covered by insurance.
I understand that there is a fee for returned checks.
___________(Patient or Guardian Initials)
Third Party Collection. I acknowledge that Surgical Specialty Group of Oviedo may utilize the services of a third party
business associate or affiliated entity as an extended business office (“EBO Servicer”) for medical account billing and
servicing.
___________(Patient or Guardian Initials)
Assignment of Benefits. I hereby assign to a Surgical Specialty Group of Oviedo ny insurance or other third‐party
benefits available for health care services provided to me. I understand h Surgical Specialty Group of Oviedo as the
right to refuse or accept assignment of such benefits. If these benefits are not assigned to Surgical Specialty Group
of Oviedo , I agree to forward all health insurance or third‐party payments that I receive for services rendered to me
immediately upon receipt.
______________(Patient or Guardian Initials)
Medicare Patient Certification and Assignment of Benefit. I certify that any information 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 Surgical Specialty Group of Oviedo by the Medicare or
Medicaid program.
______________(Patient or Guardian Initials)
Consent to Telephone Calls for Financial Communications. I agree that, in order for Surgical Specialty Group of
Oviedo, or EBO Servicers and collection agents, to service my account or to collect any amounts I may owe, I
expressly agree and consent that Surgical Specialty Group of Oviedo or EBO Servicer and collection agents may
contact me by telephone at any telephone number, without limitation of wireless, I have provided or Surgical
Specialty Group of Oviedo or EBO Servicer and collection agents have obtained or, at any phone number forwarded
or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of
contact may include using pre‐recorded/artificial voice messages and/or use of an automatic dialing device, as
applicable.
______________(Patient or Guardian Initials)
A photocopy of this consent shall be considered as valid as the original.
Patient/Patient Representative Signature:
X________________________________________________________________________Date_________________
If you are not the Patient, please identify your Relationship to the Patient.
(Circle or mark relationship(s) from list below):
Spouse Guarantor
Parent Healthcare Power of Attorney
Legal Guardian Other (please specify)__________
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