Welcome to Rosemark and thank you for choosing our office for your healthcare needs. To help you understand our financial terms, we ask that you carefully read and sign this policy and agreement. A copy will be provided for your records. Patient Account Representatives are available Monday Friday 8:00 am to 5:00 pm to answer any questions you may have.
PATIENT INFORMATION: At each visit, please provide us with name, address, phone, insurance and employment updates.
PAYMENTS AND INTEREST: The patient responsibility portion of charges or co-pay is due at the time of service. Financing options are available through a Patient Account Representative and arrangements may be made prior to services being rendered. An interest rate of 1.5% per month will be charged on balances over 90 days.
INSURANCE: As a service to our patients, Rosemark will file primary and secondary insurance claims as long as accurate and current insurance information is provided to us. "I am responsible for all charges at the time of service. My health care provider may submit insurance information to my insurance company for processing but does so only as a courtesy for me. I am responsible to pay all charges before my insurance company pays or determines the amount I owe after insurance regardless of any billing mistakes or disputes." While every effort is made to collect payments from the insurance company, patients are responsible for denied charges, non-covered services and for charges denied due to inaccurate or lack of current information provided by the patient. Please contact your insurance company for verification of coverage and preferred provider information. Rosemark is a provider for many, but not all insurance companies.
LAB FEES: The standard of care for abnormal results of blood tests, cultures and pathology may require further testing which will result in additional charges to the patient. The reference lab used to process specimens may bill the patient separately.
OBSTETRIC SERVICES: A Patient Account Representative will review the estimated charges, insurance coverage, financing options and the Obstetric Financial Agreement at the second OB visit. Routine OB care includes any service normally provided in uncomplicated cases. A routine case includes up to 13 OB visits. Any additional OB visit will be charged separately.
SURGICAL SERVICES: A Patient Account Representative will review estimated charges, insurance coverage and available financing options prior to the surgery date. The patient responsibility portion for surgical services is due prior to surgery. Please contact your insurance company for verification of coverage, deductible information and patient responsibility portion or co-pay.
OTHER SERVICES: All other services including infertility, aesthetics, blood work or services considered experimental, investigational, not medically necessary, or are non-covered, are due at the time of service. Financing options are available through Care Credit. Please ask a receptionist or patient account representative for details.
DISHONORED CHECKS: A fee of $25.00 will be charged for dishonored checks.
INSURANCE ASSIGNMENT AUTHORIZATION: I request payment of authorized insurance benefits be made on my behalf to Rosemark for medical services I received. I authorize Rosemark and its agents to release my personal medical information to my insurance company and its agents for determination of benefits payable for related services.
COLLECTION/BANKRUPTCY: If my account is assigned to a collection agency and suit is filed to recover payment, I agree to pay attorney fees of 35% of the principal and interest on my account balance, $375.00, or any amounts awarded by the court, whichever is greater. I further agree to pay reasonable court costs and costs of the suit.
If my account is assigned to a collection agency or bankruptcy status, I understand that all future medical care at Rosemark will require payment in full at the time of service.
I have received a copy (please ask for original form once electronically scanned into chart) of this financial policy and have read, understand and agree to the terms herein. I agree that I am fully responsible for all lawful debts for services rendered by Rosemark and incurred by myself or for the patient herein.
Signature of Patient- (My signature is valid for 10 years from this date)
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