FINANCIAL POLICY and PATIENT CONSENT FORM

The following is provided to avoid any misunderstanding concerning payment for medical services.

1. Payment

• Payment is expected at the time of service.
• You are responsible for any balance after insurance processes your claim.
• Any balance remaining after insurance processes the claim is billed to the responsible party indicated on the account. Accounts not paid in full after 90 days will be referred to an outside collection agency or paid using Credit Card on File information.

2. Managed Care

• All managed care (HMO, PPO, etc.) copayment amounts are due at the time of service.
• This office does not set copayment amounts.
• This office collects $125 per visit for ALL plans with deductibles that apply to medical office visits. This is an ESTIMATE of the cost of the visit. Any balance will be billed and any overpayment will be credited to the account once the claim has been processed.

3. Children of Divorced Parents

• The parent or guardian who brings the child for any visits is the responsible party.
• Responsibility for payment for treatment of minor children whose parents are divorced rests with the parent who is in our office building at the time of treatment.
• This parent is required to pay for services rendered regardless of what a divorce decree may state. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Julie Tomberlin MD PA

It is our hope that the above policies will allow us to provide the highest quality care to our patients. If you have any questions or need clarification regarding these policies, please call us at (682) 518-8111.

DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.