I authorize benefits to be paid in my behalf.
Bill primary Insurance: % Insurance Co:
Bill Secondary Insurance:% Insurance Co:
Bill Patient: Co-Payment Payment of
Per Visit Per Hr Per Weekend Live-in Holiday
Security deposit (2 weeks) of:
I am responsible to inform the Agency of any changes regarding my insurance.
I will pay any service or supply charge not reimbursed by my insurance company on a weekly basis. I will pay all charges incurred on a weekly basis if I do not have insurance coverage. If a claim is denied for home health services which the Agency has submitted on my behalf, I hereby elect not to appeal the denial myself, but I do hereby authorize the Agency to resubmit the claim for me and represent me in any negotiations. I authorize the Agency to initiate a complaint to the Insurance Commissioner for any reason on my behalf. However if payment is denied I understand that I will be responsible for unpaid services, and agree to make payment within 15 days of final denial.