Statement of Financial Responsibility

Financial Responsibility

Thank you for choosing UT Physicians, as your healthcare provider. As courtesy, we are providing you with this Statement of Financial Responsibility and encourage you to ask questions regarding this statement.

In consideration for the services to be rendered to the Patient; the Patient and/or guarantor assumes full financial responsibility for the payment of the Patient’s account.

Accurate insurance information and a copy of the insurance card(s) must be supplied by the Patient or guarantor. The Patient or the guarantor will be responsible for any co-payment, deductible and/or coinsurance deemed by the Patient’s medical insurance plan, at the time services are rendered.

The Patient or guarantor will contact the medical insurance plan to determine what benefits and services provided are covered. The Patient or guarantor understands they are financially responsible to UT Physicians for all services whether or not a covered benefit. The Patient or guarantor is responsible for all balances on the account; in which their insurance has determined patient responsibility based on plan benefits. UT Physicians recommends the Patient or guarantor confirm UT Physicians practitioners are In-network providers for the Patient’s medical insurance plan.

If the Patient and/or guarantor does not present proof of medical insurance, the patient will be deemed “self-pay” at time of service. A pre-determined minimum payment is required prior to services being rendered.

Assignment of Benefits

UT Physicians may submit requested medical information as required for payment to the Patient’s insurance plan(s). Such medical information will include the diagnoses and treatments provided by UT Physicians.

Statement of Financial Responsibility

Information provided by the patient and/or guarantor should be true and complete to the best of your knowledge. It is important for you to understand any financial responsibilities based on the terms of this document and have your questions fully answered.

Download Documents