Insurance/Financial Policy Patient Agreement
As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. The agreement of the insurance carrier to pay for medical care is a contract between you and your insurance company. Any amount not covered by your insurance company is your financial responsibility. This includes co-payment, coinsurance and deductibles. This office is not responsible for disputing decisions made by your insurance carrier regarding coverage. It is your responsibility to notify our office when either your insurance plan or benefits change. All insurance contracts require us to collect deductibles, coinsurance and co-pay amounts at the time of service.
** IT IS YOUR RESPONSIBILITY TO BE AWARE OF YOUR INSURANCE BENEFlTS**
Payment will be requested at the time of service for all services which are non-covered or determined to be patient's responsibility, including co-payments, co-insurance and deductibles. (This is the policy of your insurance company)
We will kindly reschedule your appointment if you are unable to provide payment of co-pays, coinsurance, and deductibles.
Payment for past due balances for previous services rendered is also expected when you are seen in this office. We will be happy to set up a payment plan for you.
Delinquent accounts over 60 days will be sent to collections for processing. At which point all collection fees, contingent or not, shall be added to the patient's responsibility. In the event legal action is required, the patient shall be responsible attorney's fees and cost. Please remember we will be happy to set up a payment plan for you.
Southwestern Pediatrics strives to provide the best possible care and provide availability to each of our patients. Our policy is to charge $30.00 for each missed apPOintment unless it is canceled at least 24 hours in advance. Please help us to respect and better serve each patient in our office practice by making every effort to keep each of your scheduled appointments and by calling as early as possible when you must cancel or postpone an appointment.
I hereby authorize Southwestern Pediatrics to release information required by my insurance company for payment of my medical bills or to review activities related to my healthcare provider's participation in my health plan. I assign Southwestern Pediatrics any and all benefits to which is entitled for medical services rendered.
I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY AND I AGREE TO ABIDE BY ITS TERMS.
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.
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.