BILLING/FINANCIAL POLICY

The patient must present an insurance card if we are billing.

All copays, deductibles, patient balances and noncovered services are collected on the day of the visit. If the patient has an insurance plan we do not participate with, we will request payment at the time of service for the visit and all surgical procedures.

Billing process:

  • An insurance claim is filed within 3-5 days of service.
  • If we do not receive a response from the insurance carrier within 30 days, a second claim will be submitted.
  • If we do not receive a response from the insurance carrier within 60 days, you will receive a statement & will need to contact the insurance carrier regarding payment. You will be responsible for the entire outstanding balance at this time.
  • A billing statement covering medical services rendered will be mailed to the patient monthly. However, patients are responsible for balances due upon our being notified by your insurance company.
  • Account balances that are the patient’s responsibility will be placed with a collection agency if the balance has not been paid within 45 days. Patients will then be responsible for collection costs.

If you have a financial need for a payment plan, please discuss this with the billing department before your next visit. If an extended payment plan has been agreed upon we require monthly payments or the plan is void.

We accept cash, checks, Visa & Mastercard as payment. In the event a personal check is returned from your bank, you will be charged a $20 returned check fee.

Our appointments are made on a limited basis. Please give us 24 hours notice if you are unable to keep your appointment so that we may offer the appointment to someone else with a need to be seen. A $50 fee will be charged to patients who do not show for appointments or do not give us the requested notice.

MINOR PATIENTS (UNDER 18 YEARS OF AGE)

The parent/adult/guardian accompanying a minor child is responsible for payment. We must have written pre-approval from an adult for an unaccompanied minor. Any child 18 or over is legally an adult & therefore we cannot release medical information to a parent/guardian without the patient’s written permission. If both parents have insurance, the parent with the first birthday in the year is most often the primary insurer. However, it is your responsibility to know your insurance. In divorce cases, the parent who brings the child in for service is ultimately the responsible party.

There will be a $15.00 reprocessing fee for resubmitting claims when correct insurance cards and or information has not been provided.

COLLECTION BALANCES

If you had a previous collection balance or are presently in collections, the physician may use her discretion as to seeing you again. You will be required to pay your previous balance in full prior to being seen.

I have read and understand the above billing/financial policy and agree to all terms.

Signature of patient or responsible partyDate

12/12/2018