I hereby assign to Parsley Medical, PLLC, and its affiliates, Parsley Medical PC, Parsley Medical Group FL PA, and Parsley Medical Group NJ PA(collectively, “Parsley Health”) all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any private or employer sponsored insurance for medical treatment rendered by Parsley Health. Parsley Health does not participate
in Medicare or Medicaid. The assignment will remain in effect until revoked by me in writing. I authorize the release of pertinent information necessary to process my medical claim. I also authorize direct payment to Parsley Health of all insurance or other employment benefits payable to me for such medical treatment. In the event an insurance payer or other payer pays me directly, I agree to immediately pay such amounts to Parsley Health.
I understand that my insurance or employer sponsored payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying Parsley Health for any and all amounts not paid by my insurance or employer-sponsored payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand that if my insurance or other coverage requires a referral, I am responsible for obtaining one prior to my appointment. In the event any collection action is necessary to collect amounts I owe to Parsley Health, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.
I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign and accept its terms on his/her behalf.
FINANCIAL RESPONSIBILITY AGREEMENT
Parsley Health, PLLC, and its affiliates, Parsley Medical PC, Parsley Medical Group FL PA, and Parsley Medical Group NJ PA (collectively, “Parsley Health”) committed to providing the best quality medical services (the “Services”). This Financial Responsibility Agreement (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from Parsley Health.
PAYMENT OPTIONS
*Parsley Health accepts certain insurance plans in certain states, including some plans offered by Aetna, Blue Shield, UHC, Empire BCBS NY, HIP, Oscar,Cigna, UHC UMR, GHI, Healthfirst, Centivo. Please let Parsley Health know if you have medical insurance that you plan to use for payment of the Services and Parsley will confirm whether it accepts your plan. Parsley Health also offers a self-pay option for the Services. Please see the Self-Payment of Services section below for information on self-pay options.
OPTION A: INSURANCE
As a courtesy to its patients, Parsley Health is pleased to assist in the submission of medical insurance claims to insurance companies for payment. Currently, Parsley Health only participates with and bills for Aetna, Blue Shield, UHC, Empire BCBS NY, HIP, Oscar, Cigna, UHC UMR, GHI, Healthfirst, Centivo commercial health products in New York, Aetna and Blue Shield of California commercial health products in California, and certain additional states. Parsley Health does not participate in Medicare, Medicaid or any other Health Plan.
By click signing this agreement, you understand and acknowledge that:
By click signing, you further hereby authorize payment of all medical insurance benefits which are payable to you under the terms of your medical insurance policy to be paid directly to Parsley Health for the Services rendered.
OPTION B: SELF-PAYMENT OF SERVICES
Services provided by Parsley Health that are not covered by medical insurance are 100% self-pay by our patients.
By click signing this agreement, you understand and acknowledge that: