Patient Financial Policy
You are responsible for having your current insurance and paying your co-payment at every visit.
Co-payments will be required upon check-in. Failure to provide co-payment may result in a cancelled appointment. If we must bill you for for a co-payment for any reason, a $10.00 processing fee will be added.
Due to increasing Medicare requirements and restrictions, our clinic can no longer accept new patients with Medicare as their primary or secondary insurance. If you begin care with our clinic after August 1, 2018 and later transition to Medicare as either your primary or secondary insurance, we will be unable to continue your care due to Medicare policies. Please be aware that Medicare may no longer pay for routine labs. It is the patient's responsibility to confirm this prior to completing any outside lab test(s).
The patient's insurance company will be billed if the correct information is given, and insurance payments are current. If insurance is not valid at the time medical services are provided, the patient is responsible for the Time of Service payment. The patient will authorize payment from their insurance company directly to MSFMD. The person responsible for payment agrees that all services not covered under insurance will become their responsibility and payment will be made to MSFMD.
Payments not received within thirty days of invoice will be considered delinquent and you will be contacted by our billing department for payment in full or to make payment arrangements.
MSFMD will promptly process and bill your medical services through insurance. We expect you to promptly pay your portion of your bill. If we have to send out more than one statement for patients with remaining balances unpaid, we will add a service charge of $10.00 for every additional statement and/or email/text reminder sent. To avoid additional fees, please pay your bill promptly.
Patients that are past due with no response to our billed invoices must contact our billing department to coordinate payments or if your account is past 90 days overdue, you will be submitted to a collection agency.
We reserve the right to hold medication requests and patient referrals until payment has been made or a payment plan has been established.
No show and late cancellations with less than 48-hour notice will result in an $80.00 fee. Cancellations called in after 5:00 pm on Friday or during the weekend for Monday appointments will incur a late cancellation fee. After three no show appointments, we maintain the right to discharge the patient from the practice.
As a patient of MSFMD we offer an on-call provider for urgent needs of current patients only. Non-urgent matters will be assessed, and a $40.00 fee may apply.
Time of Service appointments must be paid in full for all services provided on the date of service. No exceptions.
NSF checks and returned funds will be charged $35.00 fee and balance will be due in full with a payment of cash or credit card.
MSFMD reserves the right to change the term/fees without notice.
By signing below, I certify that the personal information provided is true and correct. I have read, understand and agree with the financial policies and terms outlined above. I understand that it is a crime to falsify information or withhold necessary information, punishable by law. I have also bee given a copy of the Privacy Policy and I understand and accept it.