The Patient or Guarantor is responsible for payment in full of all services rendered by the physicians or employees of Summit Medical Group, PLLC. Payment in full is expected at the time of service unless arrangements are made in advance.
AUTHORIZATION, ASSIGNMENT, AND RESPONSIBILITY OF ACCOUNT
I thereby authorize Summit Medical Group, PLLC to release to the above insurance companies &/or carriers any medical or other information needed for claims reimbursement.
I hereby assign, transfer, and set over to Summit Medical Group, PLLC all of my rights, title, and interest to medical reimbursement benefits under my insurance policy with the above documented insurance companies. I hereby acknowledge and accept responsibility for payment in full of all services rendered to me by Summit Medical Group, PLLC.
1404 Tusculum Blvd., Suite 3000
Michael H. Hartsell, M.D., Sonja B. Woods, M.D., Kara Lankford, PA-C, Brian Gong, FNP, Shalee Nanney, FNP