Your signature below forms a binding agreement between Bay Area Heart and the Patient who is receiving medical services or the Responsible Party. Responsible Party is the individual who is financially responsible for payment of medical care. • Bay Area Heart will assist you by billing to our contracted insurance providers. However, the patient is required to provide us with the most correct and updated information about their insurance and any changes in phone numbers or addresses, and will be responsible for any charges incurred if the information provided is not correct or updated in a timely manner. • Patients are responsible for the payment of their specialist co‐pays for each office visit, coinsurance, deductibles, and complete out of pocket expenses. • Patients may incur and are responsible for the payment of additional charges at the discretion of Bay Area Heart. These charges may include (but are not limited to): o Charge for returned checks ‐ $25.00 fee o Charge for release of medical records (copy/fax) $25.00 fee • We require 24-hour notice if you cancel/reschedule any office visit. You may notify us by phone, email, or message through the patientportal, Healow. If you fail to notify us at least 24 hours in advance, you will be charged a no-show fee. • Physician or Nurse Practitioner visit $50 fee • Ultrasounds, Stress Test, or any in office procedures $250 fee • PET CT or Nuclear Medicine $500 fee Patient Authorizations: • By my signature below, I hereby authorize Bay Area Heart to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies and other third-party payers, to obtain authorization for my treatment plan. • I understand that it is ultimately my responsibility to ensure that proper authorization has been granted by my insurance company prior to my procedures. If I am treated and no authorization was obtained and the services are denied by my insurance company, I am then held financially responsible for that date of service and treatment cost. For your convenience we do accept cash, checks, MasterCard, Visa and Discover. By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical services or as a Responsible Party, and that it is my responsibility to know the terms of my insurance.