WORK TIME:
09:00am - 5:00 pm
Saturday & Sunday - CLOSED
FIND US
17900 NW 5th Street • Building K #202
Pembroke Pines, FL 33029
CONTACT
Phone: (954) 800-1408 | Fax: (954) 842-4966
officemanager@mycife.com
A. Financial Responsibility. In consideration of CIFE providing me with health care services, I agree as follows:
1. I will be responsible, either personally (for services not covered by my insurance) or through my insurance coverage, for payment to CIFE for all services provided to me by CIFE.
2. I hereby assign payment by any third party, including private insurance and credit card companies, for all services provided to me by CIFE, directly to CIFE. I understand and agree that I remain liable for all charges and/or applicable co-payments, co-insurance and deductibles not covered by this assignment.
3. For services not covered by my insurance, I agree to pay CIFE within seven (7) days of the date of any invoice.
4. I understand that after 30 days of non-payment of any CIFE invoice that CIFE may, in its sole discretion, stop providing services to me.
5. If my current insurance policy prohibits direct payment to CIFE, I hereby authorize and instruct my insurance carrier to mail directly to CIFE any check for any payment of benefits due to me.
6.If I receive any payment of insurance benefits for services provided to me by CIFE, I will immediately forward any and all such monies, along with the explanation of benefits, to CIFE.
7. I will notify CIFE immediately upon my dis-enrollment from my current insurance carrier or any other change of benefit that could affect payment to CIFE for its services.
8. I acknowledge that it is not the insurance company’s responsibility to inform CIFE of any change in my coverage, and the insurance company will not pay for non-covered services or for services I receive after I am no longer covered.
9. I understand that I will be held liable for payment if I fail to notify CIFE if I dis-enroll from or become ineligible for coverage under my current payer(s).
10. CIFE will charge, and I agree to pay, a 1.5% monthly finance fee on all outstanding balances over 30 days and, if necessary, collection and attorney’s fees.
11. I must provide at least 24 hours’ advance notice of cancellation of any appointment by calling 954-538-0022 or such other number as CIFE mandates. CIFE may charge me a $50 cancellation fee if I do not cancel in a timely manner as required by this Agreement.
12. I also agree to pay CIFE $30.00 for any checks returned unpaid for any reason.
B. Release of Information. I authorize:
I hereby release CIFE, its designees and any person or entity providing information as contemplated above from any and all liability in connection therewith.
I have read and understand the provisions of this Agreement, I have had a chance to ask questions about the Agreement and I agree and acknowledge that I am financially responsible for services received from CIFE. I acknowledge that this Agreement binds me and my heirs, executors, administrators and assigns. I am signing this Agreement of my own volition with full understanding of its meaning.