Internal Medicine / Addiction Medicine
1676 Viewpond Dr SE Suite 100A Kentwood MI 49508
P: 616.455.9450 F: 616.455.5221
Financial Agreement and Policies
Dr. Campbell accepts all insurance plans. However, there are some plans that do not reimburse for services if Dr. Campbell is considered by the insurance company to be "out of network". We strongly advise all new patients to check with their insurance company first. In addition, there are services that are not billed to the insurance company and are paid for by the patient. Our practice is required to inform you of these non insurance paid services and obtain your signature that you understand and accept financial responsibility (i.e., "waiving your insurance rights"
For patients receiving controlled substances You will be subject to toxicology screenings as part of your medical treatment, random toxicology services are required by the DEA when prescribing controlled substances. These screenings will be given randomly at any appointment throughout the course of treatment. However, some insurance plans do not pay for this service. Dr. Campbell is permitted to offer a discount when paid at the time of service. The front desk (where you check in) is usually not aware when patients have the toxicology screening, it will be the patient's responsibility to either pay before leaving the office or within the week.
I am waiving my insurance rights, and accept responsibility to pay for this service discounted to $15 when paid at the time of service or within the week or $41 if not paid within the week from time of service, same charge for all insurance companies. (Signature)
Changing appointments less than 24 hours and No Shows: There is a $25 charge whenever an appointment is changed less than 24 hours and for missed appointments. This amount must be paid before seeing the provider again. Please initial here which indicates that you understand and agree to this policy(Initials)
Copays/Deductibles: Copays must be paid at the time services are rendered. If you have a deductible, please be expected to pay your balance at your next visit. If the payment cannot be made, patients will receive a prescription for a few days. Once a payment is made the provider will authorize and call the pharmacy to release another few days or a week. This process will continue until the balance is paid. Please initial here which (Initials) indicates that you understand and agree to this policy