PATIENT FINANCIAL POLICY
Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or manager.
As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.
Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept Visa, MasterCard, Discover, cash or check.
Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you, if you assign your benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.
We have made prior arrangements with certain Insurers and other health plans to accept an assignment of benefits. We will bill plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible at the time of service.
If you have Insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.
All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered” or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.
You must inform the office of all Insurance changes and authorizations/referral requirements. In the event the office is not informed, you will be responsible for any charges denied.
All deductibles & co-pays are collected at time of visit.
*Missed appointments may result in charges.
We request at least 48 hours’ notice for missed appointments or you may be charged $30.
For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.
Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees, and court fees shall be your responsibility. In addition to the balance due at the office.
There is a service fee of $25 for all returned checks. Your insurance company does not cover this fee.
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.