Eileen C Comia, M.D. LLC
35 Jolley Drive Suite no.102 Bloomfield, CT 06002
Tel (860)242-2200 Fax (860)242-2212
1. I understand that my health insurance is a contract between myself and the insurance
2. I understand the benefits of my health insurance plan. I know what my plan pays for
and what it does not pay for.
3. I am certain that Dr. Comia participates in my health insurance plan.
4. I have informed my health insurance carrier that my primary care physician is Dr. Eileen
5. I am aware that copays are due for payment at the time of visit.
6. It is my responsibility to bring and show my health insurance card to the physician’s
office during each visit. I understand that if I fail to bring my insurance information,
I will be held responsible for the visit until I furnish a copy of the card.
7. If, for any reason, my health insurance plan does not cover all or some of the charges
incurred from services rendered, I understand that I will be held personally
responsible for paying the balance or the full amount of charges.
8. I understand that Medicare only pays for services that it determines to be “reasonable
and necessary” according to the Medicare Program. I also understand that Medicare may
not pay for certain tests and procedures ordered by the physician. I also fully
understand that if the service/s is/are denied for payment by Medicare, I, the patient
(or undersigned guardian) agrees to be responsible for full payment of such services.
9. If my account is referred for collection, I agree to pay for the legal and collection
expenses including attorney’s fees.
I have read, understood, and agree with the information presented in this Insurance Waiver.
Name of Patient: ______________________________
Signature of patient: __________________________ Date Signed: __ / __ / ____
Name of Guardian: _____________________________
Signature of Guardian: ________________________ Date Signed: __ / __ / ____