FINANCIAL DISCLOSURE FORM AND POLICY
Our Financial Disclosure Form and Policy is designed to address the needs and concerns of our patients, and to prevent patients from being surprised with any bills that they may receive from our office. Please read this Policy, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.
We participate with many insurance companies, including Medicare, and it is your responsibility to ensure that we participate with your specific plan. Payments for all services rendered are ultimately the patient's responsibility. In order for us to bill your insurance company, patients must provide proof of insurance at each visit. If the patient does not have his or her insurance card, or if coverage cannot be verified, the patient will be responsible for payment in full at the time of the visit. We make every attempt to accurately confirm our participation in various plans, but it is ultimately the patient's responsibility to know their insurance coverage and benefits. We strongly recommend calling your insurance company prior to your visit to verify coverage. Rejection of all or part of your medical insurance claim by your insurance company does not relieve you of your financial obligation. All patients, new and returning, are required to present their current insurance card(s) at every visit as well as a photo ID
Co-payments (a fixed dollar amount that is assigned to the patient) are due at the time of each visit. They cannot be waived.
Co-Insurance and Deductibles
You will be billed for co-insurance (a percentage of total charges that are assigned to the patient) after your claim is processed by your insurance company. You will also be billed for any amounts applied to your deductible. These fees cannot be waived.
If we do not participate with your insurance company, or your insurance plan does not cover the services that the office will provide you, then the services we provide you will be considered out-of-network. You will, therefore, be responsible to pay for these services in excess of any co-payments, co-insurance, deductibles, or any costs in excess of those allowed by your plan. We will expect payment in full at each visit if the services are out-of-network, and you will be responsible to make payment in full.
Other Non-Covered Services
In some cases, your insurance company may consider the services we provide as not being medically necessary, such as cosmetic procedures. Again, we strongly recommend that you call your insurance company prior to your visit to verify coverage. If the services are not covered, you must pay for these services in full at the time of each visit. Payment for cosmetic procedures is due in full at the time of service.
Payment is due in full at the time of service for self-pay patients.
Methods of Payment
We accept cash, checks and all major credit cards. Payments may be made in person, by mail or over the phone.
Outstanding balances may result from remaining patient balances after insurance has been billed. For instance, unmet deductibles, additional co-payments, non-covered services or any other charge the insurance company may assign to the patient will be the patient's responsibility. We require all patients to provide a credit card on file at the time of each visit. Your account will be considered past due if any balances are outstanding after 90 days. Outstanding balances will then be charged to the credit card on file after notification to the patient 10 days in advance of the charge. Individual automatic charges will be limited to $200.00 and annual automatic charges will be limited to $500.00. We will request to update your credit card information on an annual basis.
Attorneys’ Fees and Costs
In the event that your account is placed with an attorney or collection agency to collect an unpaid balance remaining on your account, you will pay interest of 1.5% per month of the outstanding balance to be 5 calculated starting from the last date of service. In addition, you agree to pay for any attorneys’ fees and costs if we place your account with an attorney or collection agency to collect any outstanding balance remaining on your account. If you dispute the outstanding balance, and we have to engage an attorney to defend the dispute, then you shall be responsible for all attorney’s fees and costs incurred by us in defending against the dispute.
Credits and Refunds
Any refunds owed to your insurance company will be returned to the insurance company by check. Any credits or refunds owed to a patient will first be used to pay any outstanding balance. Remaining patient credits and refunds can be left on the account to be used towards future charges or can be returned to the patient (or responsible party who made payment) by check or applied back to the credit card used to make payment. Please allow 30 days for processing check and credit card transactions.
Cancellations, Rescheduled Appointments and No-Shows
We understand that plans change and emergencies arise. Please notify us as soon as possible if you need to cancel or reschedule your appointment. We have a 24-hour cancellation policy. Since we understand that illness and other problems may be beyond the control of the patient, we will not charge you for the first missed or canceled appointment. Subsequent missed appointments ("no shows"), same-day cancellations and same-day rescheduled appointments are subject to a $25.00 cancellation fee. These fees are applied whether or not you receive a reminder call, text or email from our office. They also apply to appointments made just one day in advance.’
When a patient is less than 18 years of age, the parent or guardian who signs this Policy is responsible for all fees incurred by the minor. As a result, it is the parent or guardian who would be sent to collections if an account is past due. When a patient turns 18 or older, he or she becomes responsible for any outstanding balance not covered by insurance, regardless of who is the insurance policyholder subscriber. If a parent or guardian wants to assume complete financial responsibility for an adult child, then the parent or guardian must sign below along with the adult child.
If your insurance changes, please notify us before your next visit so we can make the appropriate changes.
If we refer you to a provider outside of our offices, to the extent the information is available, we will provide you with the name, practice name, mailing address, and telephone number of that provider so that you can determine whether that provider participates with your insurance company. We strongly recommend that you contact your insurance company for further consultation on costs associated with the services provided by these other providers.
By signing below, you acknowledge the following: (1) You have read this Policy; (2) The office has identified to you in writing and/or its website home page the insurance companies that it has an in-network contract with, and also provided this information at the time of your appointment; (3) If the office is out-of-network with your insurance company, the office provided an estimated amount that you will be charged for the services that the office provides you; (4) If the office referred you to a different provider, the office provided you with the above mentioned information so that you may contact the provider to determine if he or she participates in your insurance; (5) You were given an opportunity to ask questions regarding this policy and your questions, if any, have been answered; and (6) You authorize CompleteCure Medical to release all information necessary regarding the services rendered to you including to you insurance company to secure payment.
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.