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 Cigna PPO, Commercial, or Open Access Plus, and I am a resident of Wisconsin, my Cigna ID card is from Wisconsin. I am aware that currently My Heart Spark P.C. accepts Cigna health insurance currently only from Wisconsin. 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 Wisconsin Cigna insurance.

I will enter my insurance details when I make my appointment or register as a new patient. I do not have Medicare or Wisconsin Cigna health 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. .