Highland Neurology
Kofi A. Doonquah, M.D.
“When Caring is Important”
2509-A Richardson Drive • Reidsville, NC 27320
336-347-7998 Phone • 336-348-6745 Fax • highlandneurology.com
Thank you for choosing us as your health care provider. Our entire staff will work toward the success of your treatment. The following is a statement of our financial policy which we require you to read and sign.
CO-PAYMENT AND/OR DEDUCTIBLE MUST BE PAID BY CASH, CHECK OR CREDIT CARD AT EACH OFFICE VISIT. IF YOU HAVE NO INSURANCE THEN YOU ARE EXPECTED TO PAY AT LEAST $80 AT YOUR VISIT AND KEEP BALANCE BELOW $200 AT ALL TIMES.
Regarding insurance:
As a service to you, we will file your insurance for all office visits, hospital visits, sleep readings and testing procedures that we perform. In order for us to bill your insurance company, you need to give us your correct insurance information each and every time you come for a visit. Insurance is a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract.
We are participating providers with the following insurance companies: Medicare, Medicaid, Blue Cross, Medcost, Cigna, UHC, Tricare and other insurance companies. Virginia Medicaid we do not accept. We file these claims. If your policy requires a co-pay plus a percentage you will be required to pay all of that on the day of service.
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary of our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
Payment of services provided to a minor is the responsibility of the adult accompanying the minor to our office and the parents (or guardians).
We encourage our patients to pay their balance in full at the time of service. If this is not possible, prior financial arrangements should be made. You will have to sign a payment agreement of $50 a month until the balance is paid off in full. This is not at every visit but each month it is expected to be paid.
I hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance and other health plans to: Highland Sleep & Neurology, Inc. I authorize Highland Sleep & Neurology Clinic to release information regarding my condition to my insurance company to receive payment for said services. I have read the Financial Policy. I understand and agree to this Financial Policy.
______
Signature of patient or responsible party Date
Thank you for complying with our Financial Policy. If you have any questions or comments, please contact us at (336) 347-7998.