We are pleased to welcome you to our facility and look forward to delivering you the highest quality healthcare.Upon verifying your insurance benefits we were informed that payment for the services being provided to you will be sent directly to your residence. We are asking that upon receipt of any such payments fromEmpire Blue Cross Blue Shield or any secondary insurer that you immediately deliver them to us either by person or by mail.

Do Not Cash these Checks

Please understand that by signing this letter you are not claiming yourself responsible for any charges we may bill your insurer, but that you are solely responsible for delivering us such payments accordingly. Once again we appreciate you choosing our office and look forward to serving you with utmost professionalism.

Sincerely,Sanchu Chacko

Patient’s signature of agreement: Clear