Last Name, First Name, Middle Initial
Patient Financial Contract with Dr. Ridha Arem
Here at Dr. Arem's office, the doctor and staff are pleased to provide you with the utmost quality care. We feel your understanding of our financial policy is important to our professional relationship. Please feel free to ask if you have any questions regarding the financial policy.
Out of Network
Dr. Arem is strictly a fee for service physician. We require full payment at the time of service. We will supply you with a copy of your itemized statement so that you may file for reimbursement with your insurance company. Should your insurance company require a more detailed description of service, please have them request it in writing. Insurance is a contract between you and your insurance company. We are not a party to your contract. We will not become involved in any disputes between you and your insurance company regarding "reasonable and customary" charges, non-covered charges, pre-existing conditions or coordination of benefits other than to supply the factual information as necessary.
Dr. Arem is not a participating provider with Medicare and has opted out of the Medicare Program. Since Dr. Arem has not contracted to accept assignments for Medicare insurance, and has opted out of Medicare, neither he nor I shall file any claims from this office with Medicare, or with any participating Medicare supplemental insurance program, for current or future medical care. I have been informed by Dr. Ridha Arem's office that I have the right to obtain Medicare covered items and services from a physician/practitioner who has not opted out of Medicare.
I, as a Tricare/Champus patient, am aware there is a 115% balance billing limitation for all medical charges. I understand that services rendered by Dr. Arem could exceed the 115% balance billing limitation. I am willing to waive my rights under the Tricare/Champus Department of Defense Appropriations Act and agree to be responsible for the difference between the billed charge and the Tricare Maximum Allowable Charge.
By providing my e-mail above, I authorize the Texas Thyroid Institute and Ridha Arem, M.D., PA to send me information via e-mail, including a monthly newsletter. I understand that my e-mail will not be shared with third-party providers and is solely for the use of this office to communicate and share information regarding thyroid health and research. I understand that I am able to opt-out at any time.