We are committed to providing you with the best possible care. Since payment of your bill is part of your treatment, we want you to be sure that our financial policies are clearly understood before we begin treatment.
We participate with most insurance plans, but it is your responsibility to call your insurance company to determine whether or not we participate with your particular plan. Please be prepared to provide your insurance card at every visit. Also, tell us if there is a change in your address, telephone number, or insurance coverage at the time of your visit. If your coverage has been terminated prior to your visit with our office, you are responsible for all of the charges incurred. All co-payments and fees are due when services are rendered. We cannot waive your co-payment, as this is an agreement between you and your insurance company. It is your responsibility to know your insurance policy requirements, such as co-payments and deductibles. We will not become involved in disputes between you and your insurance company regarding deductibles or co-payments. This office only files claims with contracted insurance carriers up to three (3) times. If your insurance company has not paid in full, the balance due may become your responsibility. If you do not have insurance, we require full payment at the time of service.
There will be a $25 no-show charge to all patients who do not give 24-hour notice of cancellation. Insurance companies do not cover this charge. If you do not show or do not cancel, this fee will be your responsibility. Anyone with a no-show fee must pay on or before your next visit in order to see one of our providers.
In the event you require an MRI or surgical procedure, a deposit will be required prior to the date of service. Our billing department will contact you once we have verified your deductible, co-payment, and/or co-insurance amounts due for your planned surgical procedure. Our practice will collect the full amount of your expected patient liability prior to your planned surgery. Failure to pay these fees can result in rescheduling or cancellation of your surgery. Please note; our fees are separate from the hospital and the anesthesiologist.
We accept cash, checks, Visa, MasterCard, Discover and American Express. There is a $25 charge for all returned checks. If overpayment occurs, we will credit your account and you may request a refund, as long as there are no other balances owed. Refunds are processed monthly and sent to the original payer in check format only.
There is a $25 charge for completion and release of forms for third party forms, including but not limited to disability and FMLA. Form services must be paid in full prior to completion. Patients requesting copies of medical records will be required to pay a $25 fee for copying medical records and x-rays. Images can be burned on a disc for an additional $10.
I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-payments and deductibles, are my responsibility. I understand that it is my responsibility to contact my insurance carrier(s) if they do not respond to payment requests made on my behalf.