Surgical Financial Requirement Agreement

(To be completed by office)

DATE:_________________________________		SURGICAL DATE:_________________________
NAME:________________________________		DATE OF BIRTH:_________________________
ADDRESS:_____________________________		SS#(last 4-digits):_________________________
______________________________________

I am aware that I am required to provide Credit Card / Bank information or a $500 deposit to hold my surgical appointment. The $500 deposit will be applied to whatever patient balance is not paid by your health insurance plan (such as deductibles, co-insurances, co-pays and/or non-covered services). Any remaining balance will be requested at time of my follow up and/or further services outside of this financial agreement. Any refund due, will be returned after claims have been processed and paid by your health insurance carrier or applied to any other outstanding balances for services rendered by Midwest Orthopaedics at Rush.

Cash: __________________________

Check #: ________________________

ACH Withdrawal:

ABA Routing # ___________________ Acct# _________________________________

Authorized Signature: ____________________________ Date: ____________________

*Please provide us with a voided check so we can verify your bank account and routing information*

Credit Card:

Cardholder Name _________________________________________________________

Last First MI

Credit Card Type: _______ Visa _______ Mastercard _______ Discover

Card Number #

Exp. Date: Month _______ Year _______

*This authorization is valid up to the expiration date on the credit card*

Authorized Signature: _________________		Date:____________________

_____________________________		_______________________
Patient/Guardian Signature		Date

_____________________________		_______________________
MOR Witness		Date

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