Financial Policy and Disclosure Form

Please correct the errors described below.

The Financial Policy and Disclosure is to help us provide the most efficient and reasonable health care services. Therefore, it is necessary for us to have a Financial Policy and Disclosure stating our requirements for payment for services provided to patients.

  • Patients are responsible for the payment of all services provided by Doctors Care and Medical Affiliates.

Self-Pay Policy:

  • If you are a self pay patient, you will be required to pay for the office visit
  • In addition, any remaining balance on your account will be collected at discharge.

Insurance Policy:

  • If you are an insurance patient, it is our policy to file for insurance as a courtesy to you,if we have accurate and complete insurance information.
  • If a service is provided that is not covered by your insurance company,you will be the responsible party at the time of service.
  • If we have not received a payment from your insurance company within thirty (30)days, you will be responsible for the balance due.
  • Deductibles, co-payments, and coinsurance will be collected.
  • In special cases we may need your help in contacting your insurance company for the payment of your services.

Overdue and Credit Balances:

  • All over-due patient balances will be sent to collections.

Divorce or Custody Case Policy:

  • The parent or guardian who brings the patient into our office will be held financially responsible, regardless of the provisions in the divorce decree, or who has custody, or who has the insurance.

To help in this policy, we ask that you assist us by:

  • Providing us with current and updated information on yourself and your insurance company.
  • Presenting an updated photo identification card and insurance card when changes are made.
  • Making the appropriate payment at the time of service, whether it is a deductible, copay, coinsurance, or for the full amount if you are a Self -Pay Patient.
  • In order to provide the best medical care, we ask that you do not discuss your account balance or financial aspects with the Physician, or medical staff. Please discuss any account information with the check out associate or front desk.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your cooperation is greatly appropriated.

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