Our practice participates in a variety of insurance plans. It is your responsibility to:
- BRING IN YOUR INSURANCE CARD TO EVERY OFFICE VISIT.
- CO-PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF THE OFFICE VISIT, IF NOT COLLECTED THERE WILL BE A $25.00 BILLING FEE. COINSURANCE IS BILLED AFTER YOUR INSURANCE COMPANY HAS PAID ITS PORTION OF THE CLAIM.
- PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE FOR ANY MEDICAL CARE NOT COVERED BY YOUR INSURANCE. IF WE CANNOT VERIFY INFORMATION AT TIME OF SERVICE WE WILL TAKE CASH PAYMENT AND REIMBURSE YOU WHEN INSURANCE IS PAID.
SELF PAY PATIENTS:
Payment for office visit is due at the time of service.
RETURNED CHECK FEE:
You will be charged $25.00 for a returned check from your bank for any reason.
This office requires a 24-hour notice if you are unable to keep your scheduled appointment. If we do not receive 24-hour notice, you will be charged a no-show fee of $25.00 for missed medical office visits.
Please allow three (3) business days from the date of requested referral.
Lab fees for blood work and pathology (including PAP smears) are separate from our office charges and may be billed directly to you by the lab company.
ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION:
I assign directly to Burrows Family Practice all medical benefits for services rendered. I understand that I am responsible for all allowable charges whether or not paid by my medical insurance. I hereby authorize the provider to release all my information if necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions. In addition, I am responsible for any deductible, copay and coinsurance amounts.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application