1.Insurance: If we are billing your insurance, it is extremely important that you furnish us with accurate and updated information so your claim can be filed. We realize that during your care, changes can occur in your insurance policy or you may have additional information, such as secondary insurance that may also need to be billed. In order for us to do our job effectively and meet your needs, please make sure to provide our office with all the information and changes. Please understand that if you do have multiple insurances, you MUST inform us of all policies. This will ensure that your file has the most up-to-date information possible.

**Please be aware that if you have an AHCCCS plan, it is ALWAYS the payer of last resort. Any other health insurance plan must be billed prior to AHCCCS. This means that if you do not provide our office with your primary insurance information, AHCCCS will not pay.

2. Proof of Insurance: We will bill your insurance with the information you provide us, at the time of service. Failure to provide us with the correct information could result in the denial of your claim. If this occurs, you assume responsibility for the entire amount of the claim.

3.Non-Covered Services: All health plans are not the same and they do not always cover the same service. Please be aware that some of the services you receive may be determined "not covered" by your health plan. You must pay for these services in full within ninety (90) days. If you have questions as to what services are covered, contact member services (the number is listed on your insurance card.) It is your responsibility to be aware of your benefits, we do not quote or verify benefits.

i. A "No Show" fee of $25 will be applied to any visit that is not canceled or rescheduled 24 hours prior to the appointment time. We understand emergencies happen, but when they do, please contact our office as soon as possible to potentially avoid any fees. Patients who No Show two or more appointments within a 12 month period maybe be dismissed from the practice and denied any future appointments. No Show fees are the sole responsibility of the patient and must be paid in full before the patient's next appointment.

4. Payments: Payment is due at the time of service. If you do not have your co-pay, your visit may be rescheduled. We recognize the need to set up payment plans for patients who require extensive treatment. Our billing department will be happy to help you with these arrangements. Any payment arrangement made but not kept current will be voided with the balance being due in full and will result in the termination of this option in the future. Any payments made will be applied to the oldest balance first.

5. Claims and statements: A claim for services will be submitted to your insurance within 45 days of your visit. You should receive an explanation of benefits (EOB) from your insurance company explaining what they paid. As a courtesy, our office will send three (3) monthly statements to the responsible party for any balance remaining. If payment in full is not made within 31 days of the first statement date, a $25 late fee will be applied. If you have questions about your bill or feel you received the bill in error, please contact our Billing Department as soon as possible to avoid any fees.

6. Delinquent account: Bills that are delinquent for more than ninety (90) days will be transferred to an outside collection agency unless prior arrangements have been made.

7. Worker's Compensation: Our office will submit a claim for worker's compensation if authorization to treat you at Family First Physicians has been given. It is the patient's responsibility to provide our office staff with employer authorization/contact information regarding a worker's compensation claim. If the claim is denied by the worker's compensation insurance carrier, it then becomes the patient's responsibility.

8. Motor Vehicle Accident and 3rd Party Billing: We do not offer any third party billing. Our relationship is with you and not with the third-party liability insurance (auto, homeowner, etc.) It is your responsibility to seek reimbursement from them.

9. Types of Payments: Our offices accepts cash, check, money order, VISA and MasterCard. Any check returned to our office by the bank will be subject to an additional $25 service fee and our office will no longer accept payments via personal check.

10. Forms: An administrative fee of $35-$75 per form will be charged for any forms that need to be reviewed and filled out by our physicians. This includes but is not limited to FMLA or disability forms, sports physicals, mission physicals, and FAA physicals.

11. Responsible Party: If the patient is a minor, the person signing these forms agrees to be listed as the Guarantor and accepts sole financial responsibility for services rendered by Family First Physicians.

Please feel free to discuss any concerns you may have with our office staff. Our staff is dedicated to making your visits with us as pleasant as possible. It is your responsibility to know what is covered by your insurance plan as well as being financially responsible for any services denied or not covered by insurance.

Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of service. Our office will not bill any other personal

I agree to pay all finance charges, late fees, collection costs, attorney fees, and any other costs that may be incurred to enforce the collection of any amount outstanding.

I have read, understand, and agree to the financial policy stated above and accept responsibility for all payment of all fees/charges incurred with Family First Physicians.