Ceeccil Quality Care Transportation

I authorize Ceeccil Quality Care Transportation LLC to verify insurance coverage and benefits and release any medical information necessary to process my or my dependent’s insurance claim.

I authorize any benefits due to be paid directly to Ceeccil Quality Care Transportation LLC. Your insurance company only provides our office with an “estimate” of covered benefits prior to receiving any services or other things from us. This “estimate” is not a guarantee of benefits.

I understand that I may be required to pay a deductible, co-pay, co-insurance, or any balance not covered by my insurance plan. If my insurance does not fully pay for services and others rendered to me, I agree to be responsible for payment of all balances on my or my dependent’s behalf.

I understand that all fees for professional services shall be paid at the time of service. Unsettled balances may be referred to an outside collection agency and the credit bureau. Returned checks will be subject to additional fees. I certify that I have read and understand the above information to the best of my knowledge.