HRPI Office Financial Policy

HRPI Office Financial Policy

Our office requires payment in full when services are rendered. If you are covered under a health insurance plan, we can submit a claim in your behalf with complete and accurate information on the date that services are rendered. If payment arrangements are to be made, they must be suitable to both parties. Our office has a variety of payment options, through cash, check, or major credit cards.

INSURANCE CLAIMS: As a courtesy to you, we will send an insurance claim on your behalf to your insurance carrier. You must assign benefits to our office if you do not pay for your services in full. After 60 days, if the insurance company has not paid your claim, the balance becomes your responsibility-this can also include interests if claim is not paid within 90 days of services rendered at a fair market rate of 18%. We reserve the right to resubmit claims to insurance carriers for which we are not contracted, one time only. Multiple resubmission of claims for the same date of service are very costly; therefore, we must adhere to this policy. If we are participating with your plan, we will submit your claim and work with the health plan for resolution and/or payment.

CO-PAYMENT/DEDUCTIBLES: A co-payment is an amount your insurance plan has determined to be owed by you on the date of services are rendered. If we are participating with your health plan, it is required you pay your co-payment/deductibles at the time of service. If we are not participating with your health plan, then payment in full, or a deposit with complete insurance information, is required. If a deposit only is desired, arrangements must be made in advance.

REFERRALS: Referrals must be produced on the day of the appointment. We do not accept faxed referrals on a later date (faxed referral prior to service acceptable(202) 543-6689 referral fax #). If you do not have your referral at the time you are seen, then (1) you must pay for your services in full and a claim will not be sent to your insurance carrier. WE DO NOT ACCEPT RETROACTIVE REFERRALS-example: COBRA-I am initialing my clear understanding of this______. (2) reschedule your appointment for a later date when you have the referral available. We do not contact primary care physician’s offices for referrals.

THIRD PARTY/LIABILITY OF CLAIMS: If your visit is prompted by an immediate crisis, you are responsible for payment in full at the time services are rendered. We will submit a claim on your behalf so that you may be reimbursed. If your visit is due to a Workman’s Comp claim, all billing information must be provided and verified by our office PRIOR to our services being rendered to you. This requires the following: (1) employer name (2) employer contact (3) Workman’s Comp insurance carrier name, address and telephone number, (4) Workman’s Compensation case number. Please note that if this information is not available at the time you are seen, you are responsible for payment on that date.

BILLING INQUIRIES: Our office accepts telephone inquiries between 9:30am-3:30pm, Monday through Friday. We use an outside billing agent______The telephone number for billing inquiries is: (202) 543-6767 (your voicemail may be forwarded to billing agent)______initial agreement (yes)

MONTHLY STATEMENTS: A statement will be sent to those individuals when prior arrangements have been made to do so. If your credit card is on file for co-pays/balances/deductibles, we reserve the right to charge your card for the following possible balances: copays(up to individual carrier plan), missed appointment fee of $110(or not canceling w/in 24 hour notice policy to (202) 669-4413(voice mail, time stamped is acceptable) or remaining balances—this is a convenience to you and we will maintain these receipts in your chart or may be sent to you upon your request(email receipt also available but please note e-mail is not always secure-basic information is included on receipt: merchant name, mailing address, amount, billing information-excluding phone number(we will only email this to you if you request this convenience). When you receive your statement, it means the balance is now your responsibility. Our statements are clear and concise. The amount you owe as of the date of the statement will appear on this statement as current amount. In the event your account becomes delinquent customer will be liable for all reasonable collection/attorney fees plus filing cost and processing fees. If you have any questions, please contact Professional Billing Services as we are billing you in accordance with the explanation of benefits statement we received from you insurance carrier. Please mail your payment promptly in the envelope provided, payments are due in 10 days from date of receipt of this statement. As of October 1, 2007, a rebilling fee of $5.00 will be assessed to any subsequent statements sent to you. We encourage our patients to contact us immediately if they feel there exists a billing discrepancy.

I (print)______have read and understood the above statements. Patient signature______Date______