- All co-payments are due at the time of visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments, co-insurance, and deductibles from patients can be considered a violation of the contract you have with your insurance company. Our office accepts cash, checks (post dated checks are not accepted), credit, and debit cards.
- Co-insurance and unmet deductibles are due prior to scheduled surgeries and procedures. Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.
- You are ultimately responsible for payment of charges for services you receive from our office.
- In accordance with your insurance member policy, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit. If you do not have insurance or do not present a valid insurance card, you will be responsible for payment at the time of service. We will provide you with a copy of our billing form so that you can obtain reimbursement from your insurance policy.
- It is your responsibility to ensure that our physician(s) is/are in your insurance network.
- It is your responsibility to know if a written referral or authorization is required to see a specialist, whether prior authorization is required for a procedure, and what services are covered. If a referral is required, it is your responsibility to obtain this prior to being seen by our provider(s).
- Not all services provided by our office are covered by every insurance plan. Any service determined to not be covered by your plan will be your responsibility.
- Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within ten (10) business days of your receipt of your billing statement.
- A scheduled appointment means that time has been reserved for you. Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment. Cancellations for scheduled surgery and in-office procedures must be received at least five (5) days prior to the scheduled surgery/procedure date and time. Patients who fail to keep, or fail to cancel a scheduled appointment within the time frames listed may be charged a $25.00 no show fee.
- A $35.00 fee will be charged for any checks returned for insufficient funds. Your insurance company does not cover this fee.
- Medical records requests must be received in writing at least 72 hours prior to the date needed.
- Administrative Services: There is a $25.00 charge for each required administrative service. This must be paid prior to completion of the service. This includes the completion of forms for work leave, the Family and Medical Leave Act (FMLA), and/or disability.
- In the event your insurance company should happen to send payment to you (the patient), you agree to forward said payment to our office to be applied to your account.
- SELF-PAY: Payment in full is due at the time of service if you do not have health insurance coverage.
I have read (or had the opportunity to read if I so chose) and understand this office’s financial policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.