Financial Policy and Agreement
1. Payments of Services: Payment of services is expected at the time or before services are rendered. Before any services are performed, you may ask to be informed of the cost associated so that you may decide whether or not to seek treatment at our facility. You may pay by cash, major credit cards, or check with a valid NYS license. All deductibles have to paid before any medical services provided.
2. Insurance: This office accepts a full range of insurance plans to offer flexibility to our patients. Your Insurance policy is a contract between you and your insurance carrier. Read it, understand it, and ask questions. It is the patient's responsibility to know what your policy covers and what it does not. Please understand that some policies from the same insurance company can have different requirements. We do expect our patients to present their insurance identification cards or enrollment forms at the time of service. Without this information we may have to reschedule your appointment or you may have to pay at the time of service. Some plans require a referral or prior approval from your primary care provider. It is your responsibility to obtain this referral. If you do not have this referral or prior authorization, you will be responsible for payment or we will reschedule your appointment. All co-pays and co-insurance associated with your managed care plan must be paid at the time of service using the options in the first section of this policy.
3. Payment Plan: Special needs are understood by this office. In cases of financial hardship, it may be necessary to set up a payment plan. If this situation is necessary for you, please bring this to our attention as soon as possible.
4. Fees: I am aware that I am personally responsible to pay all services rendered that are not covered or have limited coverage within my policy. I am also aware that in the event that my account should become past due more than 90 days, collection procedures will be implemented by Heart and Health Medical. I will be responsible for all the legal fees, collection agency fees and any other expenses involved in the collection process. A photostatic copy of this authorization will be as valid as the original.
- Bounced Check Fee $30: In the event of a bounced check, this fee will be applied to my account.
- No Show/Cancellations $30:All NO SHOW or cancellation less than 24 hours before an appointment.
- Missed Co-Payments $20. Co-payments not paid at the time of visit, will be subject to this fee.
- Medical Records: Copies of Medical records are subject to a 0.75 cents per page fee and a $15 mailing,ar processing fee.
- Special Forms - $10 per page Special forms/documents are subject to fee, other types of forms may require additional charges.
5. Insurance Denials or Non-payment: In the event that any medical service is denied by your insurance carrier for ineligibility, no referral, not medically necessary, investigational or any other reason, the remaining balance will become your responsibility. If a claim is sixty (60) days old and there has been no response from the insurance carrier, the balance due will be turned over to you. Over due accounts will be referred to a collection agency. Legal fees that we pay to secure past due balances will be added to your account. Please contact our Billing Department if you have any questions or concerns.
6.Medical information Disclosure Policy: Due to the HIPAA Privacy rules, OUR OFFICE POLICY is that we will not share or provide any medical information such as X-ray, Lab results, test results, diagnosis, prognosis, or treatment plans over the telephone. It is your responsibility to make a follow up appointment to discuss these results with your medical provider. Not receiving a phone call from our office does not indicate a NORMAL result.