FINANCIAL POLICIES

Full payment is due at the time of service unless we have a contract with your insurance company. Your Primary Care co-pay or deductible payment is expected in full at the time of service. We accept cash, checks, Visa, MasterCard, American Express, and Discover. Returned checks are subject to a $25 service fee.
You will be asked to show your current insurance card(s) and photo ID at every visit.
New patients who do not present a current insurance card will be asked to pay in full at the initial visit.
All patients without insurance will be asked to pay up front, prior to services being rendered. All self-pay charges paid in full at time of service are eligible for a 50% Prompt Pay discount apart from vaccinations wherein no discount is available.

Outstanding Balance Policy
You will be notified of all balances unpaid by your insurance. Our billing is paperless, all e-statements are sent monthly.

Regardless of insurance coverage, you are responsible for all bills being paid in a timely manner. All unpaid balances are subject to a $25 late fee after 60 days from receipt of the initial billing statement. All unpaid balances are subject to collections after 90 days from receipt of the initial billing statements. Dispute of cost-share with an insurance carrier does not exempt an account from accruing late and/or collection fees. Western Wake Wellness reserves the right at any time to suspend appointments or refer you for care elsewhere for non-payment.

Medical Records & Forms
We will release medical records with a written authorization only. There may be a charge for each request according to North Carolina statute. Medical forms that require a provider signature are subject to a $25.00 fee.

After-Hours Service Fee
Should you need to contact the on-call provider after-hours, please be aware that this may result in additional charges, which are not covered by insurance. These charges typically bill at $50 per call, based on length and complexity. Unfortunately, we are not able to handle appointment rescheduling, new prescription requests, or any medication refill requests after office hours.

Missed Appointments
All cancellations require 24-hour advance notice. For same-day cancellations and no-shows, a $45 missed appointment charge will be assessed to your account. Patients will be required to pay all missed appointment fees prior to any rescheduling. We reserve the right to suspend appointments for multiple same-day cancellations or no-shows.

Financial Agreements - DISABLED AND REPLACED WITH THE BELOW FIELD. REQUIRED TO KEEP HERE FOR NOW.
blanks*I understand and agree it is my responsibility, and not the responsibility of the provider or the provider's staff, to know if my insurance company will pay for any medical service I receive.
*   I understand and agree it is my responsibility for understanding my own coverage, benefits, co-payment, coinsurance, deductibles, and any pre-authorization requirements.
*   I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, I understand it may result in claims being denied or higher out-of-pocket cost to me.
*   I understand and agree it is my responsibility to know if my selected PCP (Primary Care Physician) assignment has been processed by my insurance company or plan. If I have requested a PCP change that has not been processed by my insurance company, I understand it may result in claims being denied or a higher co-pay/out of pocket cost.

Type a question

	Initials
I understand and agree it is my responsibility, and not the responsibility of the provider or the provider's staff, to know if my insurance company will pay for any medical service I receive.
I understand and agree it is my responsibility for understanding my own coverage, benefits, co-payment, coinsurance, deductibles, and any pre-authorization requirements.
I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, I understand it may result in claims being denied or higher out-of-pocket cost to me.
I understand and agree it is my responsibility to know if my selected PCP (Primary Care Physician) assignment has been processed by my insurance company or plan. If I have requested a PCP change that has not been processed by my insurance company, I understand it may result in claims being denied or a higher co-pay/out of pocket cost.

I hereby authorize Western Wake Wellness and its providers to bill my insurance as given and collect payment directly from my insurance for all services provided by Western Wake Wellness. I understand and agree that I will be financially responsible for all charges for services not paid by my insurance company.

Print Name of PATIENT *

PATIENT Date of Birth *

Sign the PATIENTS name *

Clear

Date *

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WESTERN WAKE WELLNESS, PLLC