I authorize the direct payment of my insurance benefits to Cerbo Clinic PC for services rendered now or in the future. I understand that all co-pays, deductibles and co-insurance must be paid the day of each visit.

I authorize Cerbo Clinic PC to submit claims for services rendered without requiring my signature on each claim. I also authorize the release of relevant information, including diagnoses, treatment records and photos for claim processing.

I understand this service is provided for me as a courtesy only and does not substitute for payment. Many insurance companies pay fixed allowances for certain procedures, while many others pay a percentage of the charge. “Reasonable and Customary Fees” are determined by the insurance carrier and may vary greatly between carriers.

It is my responsibility to pay any deductible amount, co-insurance, co-pay, out-of-pocket or any other balance not covered by my insurance company. Co-pays for surgery are due two weeks prior to the surgery date.

If my insurance does not honor this assignment, makes payments directly to me, or fails to pay within 90 days, I understand I am responsible for paying any outstanding balances.

My signature on the Patient Forms consent page confirms that I understand and agree to the above policy.