Plan of Payment

1. PAYMENT PLAN

Charges are due and payable at the time of service unless arrangements have beenmade with our office.2.

2. CASH PAY PATIENTS

You have been accepted as a patient with the understanding that all services will be paidfor in cash.If you decide to apply for Medi-Cal, you must notify our office and understand that wemay refer you to another physician or clinic for treatment.

3. INSURANCE POLICY

If you have insurance, our staff will be pleased to assist you in completing yourinsurance claims. However, we cannot accept the responsibility of collecting ornegotiating a settlement on disputed claims.

4. ASSIGNMENT OF INSURANCE BENEFITS

In consideration of services rendered, I hereby transfer and assign to Specialty Care &Surgery Center any benefits of insurance that I, or my family, may have. I understandthat my insurance company and/or Medicare may not cover all charges and I will beresponsible for balance due.

5. AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Paula R. Dhanda, MD to release insert your name any information given in the course of examination and/or treatment to satisfy my claim:*

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