Payment Policy

Digestive Diseases Consultants/Center for Digestive Health

COMMERCIAL INSURANCE & SELF-PAY PATIENTS PAYMENT POLICY

We ask that your co-pay and deductibles are paid at the time of service. If you are unable to pay at the time of your visit, we reserve the right to reschedule your appointment at a later date. For UBT testing $50.00 will be collected, the remaining will be billed to your insurance.
If your insurance carrier requires that a referral or authorization is required prior to seeing our physicians, you must present us with the appropriate referral. We reserve the right to reschedule your appointment if proper authorization is not available at the time of your appointment.
I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any services rendered. I hereby authorize Digestive Diseases/Center for Digestive Health to release to my insurance company, any information including diagnosis & medical records of any treatment or examination rendered. I also authorize and request my insurance company to pay directly to Digestive Diseases/Center for Digestive Health the amount due after applicable payments are made by me.

MEDICARE BENEFICIARIES PAYMENT POLICY

You do not have to pay at the time of service. We do accept Medicare assignment, you will be responsible for the balance of your account after Medicare’s allowed amount. If you have supplemental insurance, we will bill the balance to that insurance company. After that, any remaining unapproved charges are your responsibility.
I have read and understand the Payment Policy set forth by Digestive Diseases Consultants/Center for Digestive Health. I understand that I am responsible for having the appropriate referral or authorization on file prior to my scheduled appointment. I understand that I am responsible for the “Patient Due” portion of my bill. I understand that if I do not observe this Payment Policy, Digestive Diseases Consultants/Center for Digestive Health has the right to use other means of collection of my outstanding balance.
David Sutherland, MD, Thomas O’Connor, MD, Daniel Errampalli, MD, Brian Sasso, DO, Nikhil Bhargava, DO, Matthew Kaplan, DO, Ashish Shah, MD, Krupa Shah DO all have a financial interest in the Center for Digestive Health and the Digestive Diseases Consultants Pathology Lab.

No Shows-

For patients who do not show or cancel within 48 hours for a scheduled office visit appointment a $25 fee will be charged- for a scheduled procedure a $150 fee will be charged.

Three “no shows/late cancellations” will result in discharge from the practice.

All fees must be paid prior to scheduling a visit/procedure.

Disclaimer: 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.