OKLAHOMA CENTER TOR SPINE & PAIN
Payment Policy
By signing this form you are giving the Oklahoma Center for Spine and Pain Solutions permission to bill your insurance for services rendered in the office. Patients are responsible for copays, deductibles, coinsurance, and services that are not covered by their health insurance plans. Patient responsibility is based on an Explanation of Benefits (EOB) detailing coverage by the patient's insurance company. In the event which you do not have insurance, you understand you will be financially responsible for all visit charges. Medical insurance plan coverage and benefits vary from one plan to another. We do not know each individual plan's benefits. We cannot guarantee coverage, benefits, or payment from insurance companies, even if our office does courtesy benefit verification and gets a quote from insurance companies. Insurances determine coverage and benefits. If you have any questions about coverage and benefits, please be advised to contact your insurance carrier for more information.
With all HMO insurance plans, we require an Insurance and Provider referral.
Self-pay payments, copays, coinsurance, deductible, and past due balances are due upon arrival of appointment. Any outstanding balances must be resolved prior to your next provider visit.
Cancellation Policy
We ask that all patients/clients provide us with a valid credit card upon establishing care to be used for our 'Cancellation Policy.' Patients will be subject to the late cancellation/reschedule/no-show fee if the patient no-shows to their appointment or does not provide 24 hours of advanced notice. In-Office procedures and injections will require 7 business days advanced notice. Surgeries are a special case and require at least 10 business days advanced notice. Your credit card will be charged as follows: Same-Day Reschedule or Cancelation (less than 24 hours in advance): $100 No-Show Office Appointment: $100
No-Show Procedure/Injection: $250 No-Show/Reschedule Surgery within 10 Business Days: $750
Please be assured that all card numbers are kept in a secure password-protected system. By signing
Below, you acknowledge that you understand your financial responsibilities as a patient. You authorize payment in full via your credit card by your signature below for any and all payments due today and on the future dates of services. Please keep your credit card information updated. Questions about cancellation and no-show fees should be directed to the billing department at 405-956-3357. By signing below you acknowledge that you have had the opportunity to ask questions regarding this payment and cancellation policy and have had the opportunity to decline participation with this office. Patient Balance Policy
All balances are due upon receipt of receiving your statement. If the balance is not paid within 10 days of receiving your statement, a $25 fee will be added to your balance.