Direct Billing Consent Dr. Syb PongracicDr. Vincent Murphy& Associates Direct Billing Consent Your Full Name Child’s Full Name (if applicable) We submit the fees on the client’s behalf, as a courtesy and added benefit to our services. Direct billing does not guarantee payment and the insurance company decides whether they will pay or not. Insurance companies may do one or more of these actions: Pay part or all of the claim. Require you to submit the claim yourself even after we have directly billed them. Reject the claim payment. We are not privy to each client’s policies, payable coverage, insurance entitlement and other insurance information. Please contact your insurance company to confirm what kind of coverage you have. You understand that you are responsible for paying for services not covered by your insurance company or if they reject the claim. * Yes You have checked with your insurance company for coverage. Yes Insurance Company * Policy * Certificate * Policy Holder’s Date of Birth * Please note that your insurance company may contact us to verify your claims.Insurance companies have recently been doing more auditing. If your insurance company calls you regarding an audit, please contact our biller at billing@peakminds.ca. Codename Date Signature signature keyboard Clear Submit If you are human, leave this field blank. Δ
