Financial Policy Form

Please correct the errors described below.

Ideal Gynecology

Thank you for choosing Ideal Gynecology LLC. Listed below are our financial policies. If you have any questions, please discuss them with the office manager.

Patient Responsibility.

1. All co-payments are due at the time of the visit. Post-dated checks are not accepted.
2. Co-insurance and unmet deductibles are due prior to scheduled office visits, ultrasound, surgeries, and procedures. Once
benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.
3. You are ultimately responsible for payment of charges for services you receive from our office.
4. In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and
to present your insurance ID card at time of your visit. If you do not have insurance or do not present a valid insurance card,
you will be held responsible for payment at the time of service. We will provide you with a copy of our billing forms so that
you can obtain reimbursement from your insurance company.
5. It is your responsibility to ensure that our providers are in your insurance network.
6. If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our provider.
7. It is your responsibility to notify the office of any change in your mailing address, email and phone number(s).
8. Cancellations for appointments and procedures must be received at least 24 hours prior to the scheduled appointment.
Cancellations for surgery must be received at least 5 days prior to the surgery date and time
9. Payment is due for rendered services 7 days from the receipt of your billing statement. Unpaid previous balance must be paid
in full prior to any additional visit unless arrangements have been made with our financial counselor.


1. There will be an additional charge of 25% of the balance owed for any past due balance that is submitted to an outside
agency for collections.
2. Patients who fail to cancel a scheduled appointment within 24 hrs Monday-Friday will be charged a $50.00 No Show/Late
Cancellation Fee. Patients who fail to cancel a scheduled appointment within 24 hrs on Saturday will be charged a $100 No
Show/Late Cancellation Fee. There is a $200.00 cancellation fee for scheduled surgeries that are cancelled less than 5
business days from the date and time of surgery unless cancellation is due to insurance denial or medical necessity.
3. Medical records request must be received in writing at least 72 hours prior to the date needed. Fees for medical records are
set in accordance to with allowable amounts as defined by the state of Georgia. Fees must be received prior to record
4. The returned check fee is $30.00.

Laboratory Test Policy

In an effort to better serve our patients, your provider may order labs that are an important diagnostic tool related to your health, but that your health insurance may or may not cover all charges. You may receive a seperate bill for any tests sent to outside labs or our lab billing service company Phytest.

These tests are not included in our office charges

By my Full Name below, I acknowledge that I have read and agree to abide by this financial policy.

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