I have Medicare Part B insurance, and I will enter my insurance details when I make my appointment or register as a new patient. I am aware that currently My Heart Spark P.C. accepts Medicare Part B plans nationwide. I also understand that I will be responsible for payment of any services I have not yet paid for, if any portion of the services I receive from My Heart Spark P.C. is not covered or reimbursed by my Medicare insurance.

I will enter my insurance details when I make my appointment or register as a new patient. I have one of the insurance types and I am a resident of a specific state listed above for that particular insurance. I also understand that I will be responsible for payment of any services I have not yet paid for, if any portion of the services I receive from My Heart Spark P.C. is not covered or reimbursed by my insurance at this time.

I will enter my insurance details when I make my appointment or register as a new patient. I do not have one of the insurance types listed above or I am not a resident of a specific state listed above for that particular insurance. I understand that my insurance plan is not yet in use at My Heart Spark P.C., but hopefully soon it will be! I therefore am aware and I understand that I will be responsible for payment of any services I have not yet paid for, since My Heart Spark P.C. is not currently yet set up to accept my health insurance plan at this time.

I do not have health insurance and will be self-pay. I therefore am aware and I understand that I will be responsible for payment of any services I receive at My Heart Spark P.C. .