It is the intention of ENHANCED WELLNESS OF OAK GROVE, PLLC to provide you with a clear understanding of our financial agreements and billing procedures in the hopes of preventing any misunderstanding. If you have any questions regarding these agreements, please notify the front office coordinator. Please take the time to read, initial, and sign the patient financial responsibility form.
If you have medical insurance, it is your responsibility to fill out the insurance details on the patient form. Please provide your insurance card to the front office coordinator to bill your insurance carrier completely and accurately. If benefits cannot be determined at the time of service, or when there is any doubt, payment in full is expected. Please be advised that a medical insurance card does not inform our office of active coverage. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract and therefore do not know the details or specific benefits allowed by your insurer. As a service to you and upon your request we can bill your insurance company.
You are responsible for payment of any unmet deductible, co-payment, and co-insurance as determined by your contract with your insurance carrier. We expect these payments when services are rendered. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, you will be responsible for your balance in full. There are normal and expected times that we will need to bill your insurance company. However, if there is a time when the costs of completing your billing are over and above the usual and customary time spent processing and follow-up on a claim, we will contact you.
If at this time payment has not been received by your insurance carrier payment will be expected in full by you and you may pursue collecting personally. If payment is received from your insurance carrier you will be reimbursed. Once payment is received on your behalf from your insurance carrier any balances due for unmet deductible, co- payments, and co-insurance that have not already been collected will be billed to you and possible Finances charge will begin to apply on your account . Any bill over sixty (60) days past due will be subject to collection procedures. If you fail to make payment arrangements or set up a payment plan, your account will be turned over to a professional collection agency. Upon receipt of payment from your insurance provider, you may end up with a credit balance. Any over-payment will remain on your account as a credit to be used towards future services or material purchases. If you would like to be issued a refund, please let us know and we will issue a refund check. There will be a $30.00 service charge for any returned check. After receiving a returned check, we will no longer accept a check on your account. Payments will have to be made using cash or credit card.
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered.
I understand it is my responsibility to verify my insurance coverage prior to my appointment.
I understand that if a REFERRAL is needed from my PCP, that I am responsible for obtaining that referral. If a referral is required and I do not provide the referral number from insurance prior to my visit, I agree to pay the charges even if all claims are denied by insurance.
I understand that if a PRIOR AUTHORIZATION is needed from my PCP for any services/procedures that I am responsible for alerting Enhanced Wellness of Oak Grove PLLC at least 10 days in advance in order to have approval before the date of service. If a PRIOR AUTHORIZATION is required and I do not have an approved PA number prior to my visit, I agree to pay the charges even if all claims are denied by insurance.
We can not obtain referrals or prior authorizations on the date of service.
I agree to pay all costs of the collection, including reasonable attorney fees and court costs in the event it becomes necessary to pursue the account for collection.
I have read and understand all of the above information and have completed this form to the best of my ability. I certify this information is true and correct to the best of my knowledge.
I will notify you of any changes in my status of the above information.
I understand it’s my responsibility to ask any questions regarding cost prior to services/procedures being performed. We can provide a good faith estimate.
I understand that some lab work/specimens are sent to outside lab facilities and therefore, that facility will bill you for those services. If an outside facility is billing, then you will have to contact that company directly for billing questions.