El Camino GI Medical Associates

Financial Agreement

Thank you for choosing El Camino GI Medical Associates (EGI) for your medical care. We appreciate that you have entrusted us with your health care, and we are committed to providing you with the best patient care possible. Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your rights and responsibilities as a patient.

Please provide us with your current insurance information at the time of scheduling each visit and notify us of any changes. We must be able to verify your eligibility prior to your visit or your appointment may be re-scheduled. In addition, Failure to inform us of a change in Insurance may result in exceeding the limits of the time allowed to file a claim and you will be responsible for all charges. We will scan a copy of your insurance card and photo ID to copy and keep on file for our records in accordance with insurance plan requirements.

Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility as the Policy holder/Patient to understand the coverage and benefits and be knowledgeable of any deductibles, copayments and/or coinsurance.

It is the Patients responsibility to ensure the doctor is in-network and the services are covered under your plan. If your doctor is out-of- network, you will have a higher out of pocket cost. If you have any questions in regards to your current insurance policy benefits you should contact your insurance plans' Member Services.

It is important that we have your correct address and telephone information on file. Please advise us anytime there is any change to your address, telephone or other contact information. Failure to update our office of any changes to your contact information will not delay the billing process for any patient balances on your account.

Medicare may not cover some services your doctor recommends. All Medicare patients' procedures will be performed at El Camino Hospital, Mountain View.

Self-pay patients are those patients without insurance coverage or are receiving a service not covered by their Plan. Self-pay patients are required to pay for any charges at time of service. Self-pay rates are dependent upon the procedure being performed. For more information ask for the office manager.

Office Polices

All co-payments and past due balances are due at the time of service. In addition, we may collect a portion of your deductible if it has not yet been met. We accept cash, check or credit cards. We will bill your insurance for covered procedures. Once they have paid, you will receive a bill for any remaining deductible or co-insurance amounts owed. The balance is due in full within 30 days of receipt of the statement. Failure to do so may result in further collection activity which may include referral to an outside collection agency and/or inability to schedule any further appointments. If you are unable to pay the full amount within 30 days, please speak to the office

There will be a $25 fee assessed on returned checks.

Medical Records and Medical Forms

Should you need a copy of your medical records, please fill out our medical records release form to authorize the release of records and designate a recipient. Charges to complete medical forms (driver's license, assisted living, insurance, etc and patient-requested letters are not covered by insurance and are therefore the responsibility of the patient. Fees vary according to the length and complexity of the records requested, patient form or patient-requested letter and are determined by management

Any after-hours calls the patient requests the answering service places to the physician on call that is not deemed a true emergency by the physician may result in a $50 charge to you. This charge will not be covered by insurance and will be patient responsibility.

Missed Appointments/Cancellations

Office Visits: Our office policy is to require at least 24 hour's notice of cancellation of a booked appointment. Failure to provide adequate notice may result in a missed appointment fee from your physician. (Missed new patient appointment: $75. All other visits: $50)

Procedures: We would like you to be aware that the scheduling process for an endoscopy/colonoscopy procedure involves coordinating the schedules of your physician, the procedure room, and the necessary staff. Due to the high demand for endoscopy procedures, the procedure room is typically booked one month in advance. In the absence of adequate notice, cancellations result in a waste of key resources as it is often not possible to schedule another case in the same time slot without adequate notice. This policy stipulates (apart from exceptional circumstances) that if you cancel/reschedule your procedure with less than 5 business day notice or fail to keep your appointment, you will be charged a $200.00 fee. If you cancel your procedure with more than five business day notice no charge will be made.

I hereby assign all medical and surgical benefits to which I am entitled. I hereby authorize and direct my insurance to issue payment directly to EGI for medical services to myself and/or my dependents.

I have read and understand this policy and that the practice requires my signature and I agree to be bound by its terms. I understand I may ask for a copy of this policy which I signed. I also understand and agree that such terms may be amended by the practice on an annual basis.