Office Policies
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare and other government sponsored programs, private insurance, and other health plans to Dr. Chang. I understand that I am financially responsible for all office and emergency room charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment and assume liability for collection costs. Whether or not my insurance company pays in full, a portion, or no portion of my medical bills, is a matter between me and my insurance carrier. Unless other arrangements have been made, any unpaid balance is due within 30 days of treatment. Payment is accepted in the form of cash, check, credit card, or money order. I agree to promptly pay all charges when billed for medical services rendered and accept legal responsibility for any and all charges for payment. I hereby give my permission to have the appropriate photographs taken for the purpose of completing Dr. Chang’s records. These records are confidential and will not be presented without both my and Dr. Chang’s written permission.
