Financial Policy and Disclosure

We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.

• Payment is due at the time of service unless arrangements have been made in advance by your carrier. We accept cash, personal checks, and credit cards.
• We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will bill them, and you are required to comply with the particular requirements of your insurance including a deductible that has not been met and co-payment due at the time of your visit.
• If you are insured by a plan with which we do not have prior arrangement, we will facilitate the claim for you on an unassigned basis. This means the insurance company will send the payment directly to you; therefore, our charges for your care are due at the time of service and/or prior to procedure.
• Not all insurance plans cover all services. In the event the insurance plan to which you subscribe, determines that a service will be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
• We will bill your insurance company for all services provided in the hospital. You are responsible for any balance due for services rendered by Dr. Llaneza.
• We will ask you for your insurance card and identification (driver’s license or government approved form of identification) at each visit. All co-payments and past due balances are due and payable at the time of service.
• Some plans require that you have prior authorization from your primary care physician or PCP before you visit this practice. It is your responsibility to obtain this authorization (referral). If you do not have this referral, you will be asked to reschedule or pay for the visit your of network.
• I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees, and court costs.
• I understand that my co-payment, if applied, is “not” refundable for any reason.
• I authorize payment of medical services to Pedro P. Llaneza, M.D., PA
• A finance charge of 1.5% will be applied to outstanding balance after 90 days.
• If my insurance does not pay my medical expenses, charges will be made to my credit card that I present at this moment in the office. I will be responsible for the charges not paid by my carrier.

• Failure to keep a scheduled appointment or notify this office greater than 24 hours in advance will result in a $25.00 cancellation fee.
• Failure to keep a scheduled procedure appointment or to notify us less than 48 hours in advance will result in a $75.00 cancelation fee. If this occurs for a second time, the fee will be $125.00 cancellation fee. Thereafter, may result in dismissal from the practice. These charges are not covered by your insurance and are due and payable prior to any further appointments.
• I have read and understood the practice’s financial policy and agree to be bound by the terms stated above. I also understand that such terms may be amended by the practice from time to time.
• I have received the Notice of Privacy Practices.

“Under Florida Law, physicians are generally required to carry medical insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. After many years of carrying malpractice insurance, I have decided not to carry it now (as of October 1, 2003), because of the unconscionable escalation of rates, making it unaffordable. This is permitted under Florida Law subject to certain conditions. Florida Law imposes penalties against non-insured who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida Law”.

We are required by law to give you a copy of this notice to sign, acknowledge its receipt, and keep in your patient file.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.