Please read and agree to the conditions of registration for patient care.
Bruce J. Sachs, M.D.
501 N. El Camino Real, Suite 100
Encinitas, CA 92024
Phone: 760-944-6520 | Fax: 760-944-6525
The undersigned consents to medical examination, treatment, laboratory and radiology procedures ordered by Bruce J. Sachs, M.D.
The undersigned agrees that, to the extent necessary to determine liability for payment and to obtain reimbursement, Dr. Sachs may disclose portions of your record to any insurance company, corporation, individual, which is, or may be, liable for all or any portion of Dr. Bruce J. Sachs' charges, including, but not limited to, insurance companies, health care service plans, worker's compensation carriers, claims management companies and employers.
In consideration of the services to be rendered, the responsible party agrees, whether signing as patient, as agent, or additional financially responsible party, to pay the charges for patient's care to Dr. Sachs in accordance with usual and customary rates and terms. It is the patient's/insurer's responsibility to understand the terms, conditions, benefits, and obtain all necessary authorizations required by his/her insurance carrier prior to receiving services. Responsible party is liable except as provided by contract or law and patient accounts are due and payable in full, whether or not charges are covered by the patient's/insured's insurance benefits to Dr. Bruce J. Sachs, M.D. and to collect, bill and/or negotiate any insurance claims or benefits.
Dr. Bruce J. Sachs may check and/or verify the entire patient's responsible party's reference and financial information. Should the account be referred to an attorney or collection agency for collection, the responsible party shall pay reasonable attorney's fees, court costs and collection expenses. All delinquent accounts shall bear interest at the legal rate.