ALLERGY and ASTHMA HEALTHCARE
Maria D. Sabio MD, PC
Financial Agreement
(Please initial each line to express your understanding)
We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you anytime. Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, financial agreement or your financial responsibility.
1.___APPOINTMENTS-This practice requires at least 2 hours advance notice for appointment cancellations. A $25.00 fee will be charged to the patient’s account if a patient fails to give advanced notice and does not show for their scheduled appointment.
2.___ REFERRALS-If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER. It is then your responsibility to provide us with the referral within 24 hours or you will be personally responsible for that day’s services.
3.___CO-PAYMENTS-By contract with your insurance carrier, we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit. Should you not pay at the time of service and we subsequently send you a statement, an administrative fee of $10.00 may be added to your account.
4.___FMLA AND WORKERS’ COMPENSATION-There is a $30.00 charge for completion of Workers’ Compensation or FLMA forms.
5.___SELF-PAY PATIENTS-Payment is expected at the time of service unless other financial arrangements have been made prior to your visit.
6.___DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS-The parent who consents to the treatment of a minor child is responsible for payment of services rendered. Maria D. Sabio, MD, PC. will not be involved with separation or divorce disputes.
7.___INSUFFICIENT FUND CHECKS-a $25.00 fee will be charged to patient’s account for checks returned due to non sufficient funds.
8.___BALANCE ON ACCOUNT-Accounts with balances for 30 days or more will be subject to a 2% late fee.
9.___NON PAYMENT-Accounts with an outstanding balance for 90 days will be forwarded to a third party for collections. A collections fee of 30% will be added to the outstanding amount owed. NO ADDITIONAL CONTACT WILL BE MADE BY OUR OFFICE AT THAT POINT.
10.___PRIVACY POLICY- I have received and had time to review the Notice of Privacy Practices.
ALL FEES STATED IN THIS FINANCIAL AGREEMENT ARE NOT BILLED TO INSURANCE. FEES ARE PATIENT’S FINANCIAL RESPONSIBILITY.
I have read and understand the practice’s patient financial agreement and agree to be bound by it’s terms. I also understand and agree that such terms may be periodically amended by the practice.
______
Print Patient Name Patient Signature Date
______
Signature of Person Authorized to Consent Relationship to Patient Patient Date of Birth