Patient Acceptance of Financial Responsibility
Olde Del Mar Surgical will bill your insurance company for professional charges rendered in the office and at the facility. In the event that services rendered are not covered by your insurance company, you will be required to make payment to Olde Del Mar Surgical. Balances owed may include, but are not limited to:
- Office visit co-payments: payment of your co-pay is required on the date of service
- Annual deductibles
- Patient share of costs (i.e. coinsurance)
- Services that are not covered by your health plan
Your insurance company may require a prior authorization for initial office and/or follow up visits, certain surgical procedures, radiology exams, labs, prescriptions and/or other professional services provided to you. As a courtesy, we will contact your insurance company for authorization of services. However, it is your responsibility to understand what your insurance policy covers and assure that you have benefits and/or authorization for services. We may request your help in following up on your own for authorization requests and/or any delayed payments.
We have found that patients can sometimes be their own best advocates in facilitating a more timely approval of professional services and expedite payment of services. We suggest staying in communication with your insurance company to confirm authorization or payment has been made for services rendered or requested. Should you have any questions you can reach Jocelyn in our billing department at (858) 272-8853. Should you and Jocelyn come to a financial payment agreement for services rendered, but you fail to notify Jocelyn of any changes and become noncompliant, the agreement made will be null and void and full balance due immediately.
We look forward to seeing you at your next appointment and value the importance of regularly scheduled visits for your overall health and wellness. Thank you.
Late Arrival/No Show-Cancellation Policy
Late Arrival Policy:
- We will do our best to see you at your scheduled appointment time. You should expect to be rescheduled if you are more than 15 minutes late.
No Show/Cancellation Policy:
- We require that you give our office 24-hour notice in the event that you need to cancel or reschedule your appointment.
If you fail to show up to your scheduled appointment and/or cancel with less than 24-hours notice, you will be charged a $50.00 no show/cancellation fee for each cancellation or no show.
Patient agrees and acknowledges that the $50.00 charge is pre-authorized in the event of a cancellation or no show.
I have read the above and understand my financial obligation and late arrival/no show policy.