It is necessary for our office to enact the following policies effective January of each year due to the
increase in high deductibles, co-insurance portions, co-payments of insurance companies’ pending claims and withholding
payments. Please feel free to ask for clarification if necessary.
Your office visit, PFT Pulmonary Function (breathing) Test, sleep study take home device,
Labs (orders sent out), CPAP, or CPAP Supplies and Spirometry might not be paid by your insurance.
I hereby give authorization to Dr. Shahrukh Kureishy/Dr. Ferzana Mir and their staff to provide medical treatment. I understand
that no guarantees have been made with regards to treatment success, and that there may be complications associated with the
condition or with its proposed treatment. By signing below you are agreeing to pay for these services yourself, even if those are
determined by your insurance as not to be “medically necessary.”
We ask for your insurance information when we schedule your first appointment, and we make every effort to verify your
benefits for procedures that are common in our practice. While we do our best to verify that our doctors are contracted and in
network with your insurance plan, it is ultimately your responsibility that this is the case. Based upon information provided to us
by your insurance company we will expect payment according to the benefits quoted. Your copayment, co-insurance or
deductible per your insurance company, and as indicated on most insurance cards will be collected before seeing the doctor. We
will then file your office visit superbill with your insurance company. However, you will be responsible for your portion after
your insurance pays, and as it indicates on your EOB. Also, we will not be held responsible if you or your accompanied person/s
falls and injures in or outside our office. Any outstanding balance will be due and payable upon receipt of the statement.
Many insurance plans have a requirement that patients must provide additional information to them before they will pay your
claim. When this is the case, your insurance company will inform us that they have “pended” your claim for additional
information. If that happens, the full balance due on your visit becomes your responsibility. Once an insurance company “pends”
a claim, there is nothing that our office can do to get the claim paid. It is completely your responsibility to contact your insurance
company to provide them the needed information so your insurance company pays the claim within 30 days. Additionally, you
must notify us at the time of service if your insurance plan, group, or policy number changes so we can file your claim precisely.
Visits that have been filed by us in a timely manner but denied by your insurance after 60 days will
become your responsibility. Please remember that our office files to your insurance as a courtesy to
you. It is important to remember that your insurance policy is a contract between you and the
I also understand that failure to appear on scheduled follow up or new patient visit appointment may result in a delay in the
diagnosis, and treatment of a potentially serious condition. We call in advance to remind an upcoming appointment, and/or
reschedule if the appointment cannot be kept. However, we will not be held responsible for complications arising from missed
appointments due to the patient’s noncompliance.