Home / Patients
Step 1 of 4
FINANCIAL RESPONSIBILITY: As consideration for the services provided to you, you guarantee payment for any amounts due for such services provided by Nephrology Specialists of Oklahoma. Charges for services and goods shall be at Nephrology Specialists of Oklahoma billed charges rates unless otherwise agreed to in writing by Nephrology Specialists of Oklahoma. I hereby assign to Nephrology Specialists of Oklahoma all payments for medical services rendered to myself or my dependents. I understand that I am responsible for amounts not covered by insurance. I
further understand it is my responsibility to notify Nephrology Specialists of Oklahoma of all address, phone number, and insurance information changes. Medicare recipients are responsible for 20% of allowed charges, deductibles, and co-insurance amounts. Other insurance patients are responsible for their co-payments and deductible at the time of service.
ASSIGNMENT OF INSURANCE BENEFITS: You agree that insurance benefits for Nephrology Specialists of Oklahoma charges payable for the insured are to be made payable to Nephrology Specialist of Oklahoma and that insurance benefits for services provided by physicians in the practice setting, otherwise payable to the insured are to be made payable to the physician(s) responsible for your care. Any payment received for this episode of care may be applied to any unpaid bills for which you are liable, subject to the rules of coordination of benefits.
PATIENT’S CERTIFICATION: I hereby certify that I have read each of the above statements and that I am the patient or legally authorized representative to accept the terms of this patient agreement and may receive a copy of this patient agreement.
Payments are due at or before time of service unless other arrangements were made with our office prior to services.
If you would like Nephrology Specialists of Oklahoma to be able to talk in person or on the phone to anyone including spouse or family members regarding your appointments, medical results or provide any medical information, you will need to list them below.
I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by the following:
A complete description of how your medical information will be used and disclosed by Nephrology Specialists of Oklahoma is in our
NOTICE OF PRIVACY PRACTICES, which can be given to you by Nephrology Specialists of Oklahoma at your request.