For all medical services provided in this office, inclusive of diagnostic laboratory testing and/or radiology studies, payment is due at time of services. Unless other arrangements have been made in advance with our Business Office, payment is expected upon checkout in cash or, with proper identification, by personal check, VISA, MasterCard, Discover, or American Express.

For our patients with medical insurance coverage, the appropriate co-payment is due at registration and the known deductible, or non-covered billable portion of the charges are due and payable at the time of service.

For self-insured patients, for services exceeding $100 on the same day, a 20% cash discount will be given for payment in full.

In a divorce or separation case where a child is being treated, regardless of who has been awarded custody or financial responsibility for the child, the person bringing the child for treatment is responsible for the payment of services rendered at the time of service.

When patient insurance coverage is confirmed, SAMA will file the remaining claim amount with the patient’s primary insurance. The patient is responsible for filing claims to their secondary insurance carrier.

After your insurance processes a claim, all remaining amounts after contractual adjustments shall be patient responsibility and due in full. When patient insurance fails to respond to a properly filed claim 30 days after our submittal, any remaining amounts shall be patient responsibility and due in full.

Miscellaneous Fees may be added to your account as follows:

 - $20 – Missed “confirmed” appointment without at least 2-hour notice before   scheduled start
 - $20 – After-hours call to our on-call Provider
 - $10 – Prescription requests received and filled without an office visit
 - $10 – Medical advice/care given by phone – after first 10 minutes
 - $20 – Special patient requested forms requiring direct supervision of a Physician

Payment arrangements: SAMA Healthcare Services is not, and has no desire to be, a financial institution which extends “credit” to its patients. We work with our patients on a case-by-case basis in which account balances must be paid off within 6 months from date of service. Please contact our business department with your specific request.

Patients with account balances will receive a monthly statement of activity. Payment in full is due upon receipt of statement unless specific payment arrangements have been made with our Business Office. Accounts that are not paid in full will be charged a $5 monthly fee until the account is paid in full.

We will make every effort to work with you and your insurance carrier, if applicable, to keep your account current. If circumstances of non-compliance and/or non-cooperation persist, we reserve the right to take whatever legal or other action is necessary to bring your account current, including, but not limited to, outside collection proceedings and/or termination from the practice. An additional fee equaling 40% of your unpaid balance will be added to your account if outside collection proceedings become necessary. All accounts over 90 days will go to collections.

I have read, understand, and agree to this Financial Policy.