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Form W 9 Fort Wayne Indiana: What You Should Know

Enter your legal name in the fields provided for this purpose. Giant Medical Center Fort Wayne 46818 Fill out the form on the right side, but leave space for your signature at the top. Payment Methods Accepted Visa, MasterCard, Discover, Diner's Club, Amex, American Express Payments via mail or through your bank are not tax-deductible. Any other method of payment is subject to a 2.9% fee (minus any applicable state and local taxes) by the financial institution. Payment can be made by credit card, debit card, cash, or check; money order, cashier's check, personal check, or money order with bank check. Check or money orders are acceptable as payment if they are made payable to Giant Medical Center and cleared by the bank prior to the date of invoice. Payment may be made for up to six (6) months from the date you first visit the Giant Center. If you wish to have medical services provided by a different provider than those offered at the Giant Center, contact the provider directly. If the Giant Center has a contract with a provider, you will receive the same billing at any Giant Medical Center. If you do not wish to have your bill paid by the Giant Medical Center, you can choose not to have it billed to you. If a payment is received after six (6) months after the start of service, the medical services will not commence until that period has passed.   The Patient is responsible for all of his/her portion of the charges for his/her medical services or a part thereof. The Patient agrees that if his/her medical records are subpoenaed by the court for the purpose of collection from him/her, that they are protected by applicable laws and regulations. Medical Billing Medical Bills may be obtained in person on the main building or at any Giant Medical Center during regular business hours, Monday through Friday, by calling. A patient/caregiver may be represented by a lawyer at no cost. It is recommended that the patient file or have the patient's physician document all medical bills. Health Insurance The Giant Center does not do health insurance. Health insurance companies will charge an administrative fee of 25 per visit. For those who receive health insurance at work, they will be required to pay 6 per visit.

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