Financial Policy

Financial Policy and Authorization

We are happy that you selected Golden Eagle, Inc. DBA: GE Medical Service - Telmedicina Latinafor your healthcare needs and look forward to working with you. To help you understand your financial responsibilities in relation to your medical care, we would like to briefly outline our financial policies.

Patients are financially responsible for all services provided and are expected to pay for services at time of service, including any past due balance from a prior date of service. If the patient is a minor child, the parent or other adult accompanying the child will be financially responsible regardless of legal guardianship.

Medicare: The office will provide a detailed receipt for payments and that may be submitted to Medicare for reimbursement.

Medicare Supplemental and Secondary Insurances: The office will provide a detailed receipt for payments and that may be submitted to Medicare for reimbursement.

Medicaid: The office will provide a detailed receipt for payments and that may be submitted to Medicaid for reimbursement. Medicaid patients are responsible for securing necessary referrals from their primary care physicians.

HMOs and PPOs, Commercial Insurance Plans: The office will provide a detailed receipt for payments and that may be submitted to your insurance carrier for reimbursement.

Self-Pay: Patients are responsible for payment in full at the time of services for all services rendered.

Out of State Insurance: The office will provide a detailed receipt for payments and that may be submitted to your insurance carrier for reimbursement.

Authorizations and Consent

ASSIGNMENT AND RELEASE: I also authorize Telemedicina Latina to release any information required to process my claim to my insurance carrier and/or to my employer or prospective employer (for employer sponsored/paid for claims). I acknowledge that I am financially responsible for services rendered, and failure to pay any outstanding balances may result in collection procedures being taken. Further, I agree that if this account results in a credit balance, the credit amount will be applied to any outstanding accounts of mine, or to a family member whose account I am guarantor for.

I understand the Financial Terms and Authorizations and hereby agree to them