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Home » Patient Resources » Forms » No Show Fee Form

No Show Fee Form

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Assignment of Benefits Form

  • • The undersigned, hereafter referred to as “the patient,” do hereby assign all of my rights and interests to Center for Bariatric Endoscopy, hereafter referred to as “the medical provider,” to pursue and obtain payment from the above-mentioned insurance carrier. The assignment shall include but is not limited to, all rights available to me pursuant to the Personal Injury Protection Statues of the State of New Jersey.
    • I assign, to the medical provider, all my rights and benefits under the insurance contract for payment for services rendered to me. Upon consent of both parties, same shall be revocable.
    • I, the patient, do hereby understand and acknowledge that if I willfully refuse to comply with reasonable requests of the insurance carrier, payment of my medical bills may be denied and I will be held responsible for same.
    • I, the patient, authorize my bodily injury attorney to pay directly to the medical provider any monies due on my account or have same deducted from any settlement made on my behalf.
    • I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health insurance carrier and/r other insurance carrier fail to forward the check to the medical provider, I will endorse and sign the check to the medical provider within five (5) days of receipt.
    • I, the patient, do hereby acknowledge that I will not file suit and/or obtain arbitration for the payment of the above provider’s medical bills unless I am requested to do so by the medical provider. I understand that the above referenced medical provider has an attorney and will collect payment on my behalf from the insurance carrier.
    • To prevent the insurance carrier and/or the vendor designated by the insurance carrier from refusing to accept my assignment or submitting a challenge to my assignment as being invalid, I execute this special Power of Attorney and appoint and authorize the medical provider and counsel on behalf of the medical provider to file suit and/or arbitration directly against the insurance carrier in my name and/or allow the medical provider to amend the lawsuit and/or arbitration directly against the insurance carrier in my name and/or allow the medical provider to amend the lawsuit and/or arbitration to include my name. I understand and acknowledge that the attorney chosen by the medical provider is to represent me individually on any claim for outstanding treatment with the medical provider in any appropriate forum. This assignment serves as a limited retainer agreement between me and the attorney chosen by the medical provider for the sole purpose of representing me on a claim for outstanding treatment. I have been advised that if an arbitration and/or lawsuit is filed in my name individually, failure to include an outstanding medical provider’s bills whom I have not executed an assignment of benefits with could make me liable for payment to that provider. In consideration, this medical provider has agreed to accept as payment in full, the amount awarded and/or settled and will not seek additional payment from me. This does not preclude the medical provider from seeking additional payment from other insurance carriers.
    INSURANCE SIGNATURE ON FILE:
    I authorize Sohail N. Shaikh, MD or any billing company he is in contract with to complete any necessary insurance Claim Forms on my behalf and permit the release of any medical or other information which may be needed in order to process said claims. I authorize a copy of this “Signature on File” form to be referred to when insurance claim forms are submitted for healthcare services I have received (including to the Centers for Medicare & Medicaid Services and agents, along with any Medicare Supplemental Insurance carriers if applicable, in the case of Medicare).
 

Verification

No Show Fee Policy Form

  • Due to a high patient demand and the limited availability of appointments, Center for Bariatric Endoscopy has instituted a $50.00 no-show fee/late cancellation fee for missed appointments not cancelled at least 24 hours in advance. If you need to cancel or change your appointment, please call us at least 24 hours in advance to avoid being charged this fee.
    I understand the no-show policy and agree to pay the $50 no-show fee if I do not show up for my scheduled appointment and do not call the Center for Bariatric Endoscopy at least 24 hours before my appointment to cancel.
 

Verification

 

“Individual results may vary.  Results are not guaranteed with this or any other procedure. Any weight loss procedure should be accompanied with nutritional counselling and an appropriate diet and exercise program.”