Thank you for choosing Forward Care Family Practice. We are committed to providing the finest personalized family care. Please carefully read and sign the following statement of our office policies prior to your treatment. Feel free to speak to our practice manager or billing department if you have any questions.
It is ultimately the patient's responsibility or their responsible party to know their insurance coverage and therefore responsible for copays, deductibles, denied services by insurance. Due to a large amount of Insurance plans/policies, it is impossible for the physician or staff to know what services are/or are not covered. It is the patient's responsibility to be aware of the services covered by your health plan. You are ultimately responsible for payment of services if your insurance carrier does not pay for any reason. IT IS THE RESPONSIBILITY OF THE PATIENT OR THEIR RESPONSIBLE PARTY/REPRESENTATIVE TO KNOW THEIR INSURANCE COVERAGE. Please present your insurance card at each visit. Insurance companies deny claims that are not submitted within 90 days of the date of service. If you do not submit your current insurance to the office at the time of your visit, you may be responsible for denied claims. We attempt to verify coverage before your visit with the information you provide. Verification of coverage does not guarantee the insurance company will pay for your visit. Insurance policies exclude some non-covered services; however, this does not mean services or tests are not necessary. It means the policy you have does not cover certain necessary services. Please keep in mind your insurance policy is a contract between you and the insurance company. The physician has no control over which services the insurance company does or does not cover.
The patient is responsible for obtaining all necessary information regarding referrals or authorizations to another physician. Failure to do so may result in denial or delay of payments. Referral will be done at appointment only. Please be sure to bring your insurance card to every visit to ensure we have the most up to date information.
NO SHOW/LATE CANCELLATION FEE:
If you need to cancel your appointment, please contact our office at least 24 hours before your appointment time. Because of the high demand for appointments, missed appointments prevent us from scheduling appropriately and to care for others in need of urgent care. A $50.00 fee will be assessed for all missed appointments not canceled with at least 24 hour advance notice. Two appointment reschedules will automatically incur a $50 No Show fee. Should you no show or late cancel repetitively, we may discharge you from our practice.
As a courtesy to you, we will bill your insurance company for services rendered. In order to do so, we must have a complete billing information, picture identification, and your insurance card. Arizona law requires insurance companies operating in the state to process claims within 30 days. It is your responsibility to promptly provide your insurance company with any requested information needed to process your claim.
In order to keep billing costs to a minimum, all co-pays, co-insurance, and deductibles are to be paid on the day of the visit without exception. We reserve the right to reschedule your appointment if the applicable co-payment is not paid in full at the time of appointment check-in. For your convenience, we accept credit, and debit cards from Master Card, Visa, and Cash.
In addition to co-payments and deductibles, you are responsible to pay for denied or non-covered services as determined by your insurance company. If our physician is an “out of network provider” for your insurance, the deductibles and co-insurance amounts may be higher. Your insurance policy, not our office, determines the amounts. After your insurance company processes your claims, you will receive a statement every month from our office showing your account balance. Your statement will indicate which portion of the balance is due from you. Patient balances are due and payable in full upon receipt of your statement. Accounts which remain unpaid after 30 days will be assessed a late fee of $5.00 per month. Delinquent accounts will be transferred to a collection agency or our attorney after 90 days.
In the event of default, you will be required to pay collection costs and reasonable attorney fees. Accounts sent to collections are reported to all three major credit bureaus and are on file for as long as the law provides.
Please understand maintaining financial viability is the only way our office is able to continue providing quality medical care for our patients. Your understanding and cooperation enables us to deliver the quality healthcare you deserve and expect.
Please plan ahead for prescription refills. We encourage you to address refills at the time of your office visit. Any changes in medication, new prescription, or mail-in prescription problems require an office visit. No prescription refills will be granted on weekends, after hours, or during routine well visits.
We respect your time and every attempt is made to run on schedule. Therefore, we ask you to arrive on time for your appointment. If you are late, you may be asked to reschedule. If your provider is running behind due to emergencies and you need to reschedule, please notify the office staff. If you choose to stay, your visit will be given the same consideration.
FMLA (Family Medical Leave Act) of Short Term Disability forms are not included with your medical care. We will complete your forms if you qualify. There is a fee of $95.00 for each form due and payable prior to the provider completing the form(s). You must make an appointment in order to determine eligibility. This is not covered benefit by your insurance company.