- Insurance co-pays are due at the time of your appointment. Your insurance policies may require you to make a copayment or pay a deductible for an office visit, a diagnostic test and/or a procedure; therefore, payment is expected on the date of service.
- Our office accepts many health care plans. We will bill those plans with which we have an agreement and collect co-pays and deductibles at the time of service. In the event that your insurer determines the service is “not covered” by the terms of your health care plan, you will be responsible for payment in full on the date of service(s) to include office visits and procedures.
- In the event that our physician(s) are not enrolled with your health care plan, you will be responsible for payment in full on the date of service(s). In this instance, you may submit your claim directly to your carrier to request reimbursement.
- In the event that your medical expenses will not be submitted to an insurance carrier, payment is due at the time of service to include office visits and procedures.
- Many insurance companies require an authorization for visits to receive full benefit coverage. If you are unsure if authorization is required, please call your insurance carrier directly. If required, the authorization must be received before your visit. Failure to provide us with the proper authorization may result in the rescheduling and/or cancellation of your appointment.
- For appointments that are missed and not cancelled at least 24 hours prior to the scheduled office visit, there will be a $25 no-show fee charged.
- Form fees are not covered by your insurance company. Therefore, there will be a $25 charge for each form. This is to be paid in advance. A physician may complete one form at no charge during an office visit.
Financial Agreement
I hereby assume full responsibility for all charges incurred for professional services rendered by Greensboro Medical Associates, P.A. and its assistants, including 33 1/3% collection costs, unless the services are deemed “paid in full” as a result of a contractual agreement between Greensboro Medical Associates, P.A. and my insurer.
Authorization for the Release of Information
I hereby authorize Greensboro Medical Associates, P.A. to release any medical, psychiatric, infectious disease (including AIDS confidential information) or drug and/or alcohol related information to my referring physician and any insurance company with whom I have medical benefits for the purpose of filing a medical claim. I acknowledge that this authorization is valid until such time as all medical bills related to my treatment have been paid. I further understand that I can withdraw this consent for release of information at any time prior to this expiration date except to the extent that action has been taken in reliance hereon.
Group & Individual Insurance, Assignment of Benefits
I authorize my health insurance benefit plan to pay directly to Greensboro Medical Associates, P.A. for services rendered. I understand that I am financially responsible to Greensboro Medical Associates, P.A. for charges not covered by this assignment.
I acknowledge that I have read and agree to the financial and privacy policies of Greensboro Medical Associates, P.A.