Financial Policy Form

Please correct the errors described below.

Miriam M. Torres, M.D. Serenity GYN and Functional Medicine 220 N. Park Blvd, Suite 100 Grapevine, TX 7651

Office Hours Monday-Thursday 8:30 am - 5:00 pm Friday 8:30 am - 1:00 pm

Financial Policy

Payment at time of service

Dr. Torres participates in most insurance plans and we will file your insurance for all plans for which she is a contracted in-network provider. We do require all co-payments, co-insurance and deductibles be paid in full at the time medical services are rendered. We do accept cash, checks, debit cards, MasterCard, Visa, American Express, Discover and Care Credit. This portion is based upon an estimate of your co-insurance/deductible and coverage, and any remaining balance due after your insurance carrier pays will be your responsibility. You will be billed, and payment is due upon receipt. It is your responsibility to provide us with your most current billing address, telephone numbers and insurance information at each appointment. We also require the social security number of the patient or guarantor for collection purposes.

Health Insurance Procedures

It is your responsibility to bring your most current insurance card to each appointment.  If there are any changes in your insurance information, please bring this to our attention.  If the wrong insurance is billed and your claim is denied you will be liable for full payment.  Please be sure to contact your insurance company directly to ask any questions you may have regarding your coverage and benefits prior to your visit. Every policy is different, and some labs and procedures may not be covered or may be subject to a deductible- it is your responsibility to know your benefit plan and what are covered and non-covered services.  Our office will be glad to provide you with any information you might need. If your claim is not paid in a timely manner or pended for information from the patient or for a pre-existing investigation, it is then the patient’s responsibility to assist in resolving these claim issues.

Prescription and Medication Refills

To ensure that you have your medication when you need it, please contact your pharmacy and have them fax a refill request to us during regular business hours. Refill request are handled only during regular business hours. Request for antibiotics and certain medications will require an examination by Dr. Torres If you have any questions or concerns regarding medication, please call our office and ask to speak with the nurse or medical assistant. Please allow 24-48 hours for processing.

Acknowledgement of Practice’s Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if I so choose) and understand the Notice of Privacy Practices (NPP) and agree to its terms. To file a complaint with the Texas Medical Board call 1-800-201-9353

Records Release

I hereby authorize Serenity GYN and Functional Medicine to furnish any medical records and/or other necessary information needed to process an insurance claim.

Consent to Treat

I authorize medical treatment by Miriam Torres, M.D. and her staff. I authorize payment of medical benefits to Southlake GYN and Wellness dba Serenity GYN and Functional Medicine.

My signature below represents my agreement with the above written policies.

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