OUR FINANCIAL POLICY
° This policy covers office visits, procedures, lab, or other testing performed. By signing below, I agree to the terms of this Financial Policy.
° MEDICARE PATIENTS: I am a participating physician with Medicare. This means that you will be responsible for the 20% of the Medicare approved fee for covered services, the yearly deductible and full payment of any non-covered services. Non-covered services include but are not limited to most diagnostic tests performed for screening purposes. We will provide Medicare with your supplemental (secondary) Insurance so that they may file that for you (Medigap policies only) if you do not have Medigap crossover policy you will be responsible for filing your secondary insurance.
° PAYMENT IS DUE AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate (please see insurance below). Returned checks will be charged a $25.00 service fee, no exceptions. If a check is returned to my office, you will no longer be able to pay by check for services rendered.
° INSURANCE: Patients will be asked to present their insurance card for copying upon check-in at the office the first time they are seen for medical services. Please inform us on subsequent visits if your insurance has changed. Claims not paid within 45 days by your insurance company will become your responsibility. You will receive a statement for these services, and you will need to contact your insurance company for reimbursement.
For those patients in insurance plans with which we ARE a participating provider, all co-payments, deductibles, and non- covered services are due at time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan where I am not a participating provider, we will require payment in full at the time of service. Due to the thousands of insurance plans available it is impossible for us to know the coverage details of all of the policies. It is your responsibility to know what type of coverage, benefits, deductibles and co-payments you have with your insurance plan.
CANCELLATION/NO SHOW POLICY FOR DOCTOR APPOINTMENT
We understand that there are times when you must miss an appointment due to emergencies or obligations with work or family. However, when you DO NOT call to cancel an appointment, you may be preventing another patient from getting much-needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly ”full” appointment book. Also, when you DO NOT call 24 hours in advance, you will be charged a $50.00 fee.
Pathology Notice: Certain tests that you have done in the office will be sent to a pathologist for diagnostic evaluation. The pathologist will submit a bill to your insurance company and bill you directly if there is a balance due.
Surgery Cancellation Policy: A fee of $250.00 will be charged if you cancel a scheduled surgical procedure with less than a 30- day notice.
Assignment to Pay for Services: I agree to pay for all charges for services rendered today, or any future date of service, in this office. If payment is not received from either you or your insurance company within 60 days from the date of service, your account will be considered delinquent. I further understand, in the event this account is referred to an agency or attorney for collection, I will be responsible for all collection fees, attorney's fees and/or court costs.
Signature:
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(We will ask you to sign this when you come into the office for your appointment)