blue shield ppo payment agreement
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8/3/2019 Blue Shield PPO PAYMENT AGREEMENT
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the Los Angeles Mobile Acupuncture group
PO Box 352116
Los Angeles, CA, 90035-1515
(866) 629-8089
Blue Shield PPO Policy Holders
Los Angeles Mobile Acupuncture is out of network with Blue Shield PPO. As a courtesy
to our patients we bill Blue Shield for services rendered in our office. Blue Shield will
reimburse you directly for the treatment you receive. Blue Shield does not make anypayment directly to our office. When you receive payment from the insurance you will
be responsible for payment to our office. The amount you will owe is inclusive of the
amount Blue Shield pays you as well as any deductible or copayment portion which may
be due.
We ask that you bring all explanations of benefits (EOBs) from Blue Shield to our officeso we can determine the amount you owe. Blue Shield does not always send the EOBs
to our office. If our office does not receive any information from Blue Shield or thepolicy holder within 60 days of billing you will be responsible for the amount billed.
______________________________________Name
______________________________________ _______________
Signature Date
Credit Card Authorization
I, ____________________ (card holders name), authorize the Los Angles MobileAcupuncture group to charge my credit card for services rendered.
Patient Name:___________________ Name as it appears on card:__________________
Credit Card Number:________________________ Exp. Date:__________
Card security code:_______
Signature:_________________________________ Date:___________