OFFICE, FINANCIAL and PHONE MESSAGE POLICIES – Kirana Kefalos MD, LLC

Welcome!

I am committed to providing the best care possible and I appreciate your trust. I look forward to working with you.

_____ If you have health insurance please understand that this is an agreement between you and your insurance company; you are responsible for knowing your benefits. We will be happy to assist you in any way, but you are ultimately responsible for timely payment of your account. If inaccurate information is given to our office we are not held accountable.

Copayments are due at the time of the visit.

Charges for any service not covered by insurance are due at the time of the visit.

Referrals:You have a choice about where to receive diagnostic testing, health care treatment and services. Please speak to Dr K about your preference when a referral is needed. Please contact your insurance company for additional information.

If I am a participating provider of your insurance company:

We gladly submit claims to your insurance carrier. We also offer secondary and tertiary billing.If you have not met your deductible at the time of the visit you will be expected to pay the amount which your insurance company would pay for the service. This will apply until your deductible is fully met.

If I am not a participating provider of your insurance company:

We will gladly submit claims to the insurance carrier. Generally insurance companies pay a certain percentage towards out of network visits. You will be required to pay us the amount that your insurance does not cover.

Medicare: I have opted out of Medicare. No service I provide can be billed towards Medicare either by this office or by you. I do see Medicare patients who self-pay.

Timely payment of your bill. We take many steps to avoid collections. However if your account is placed with a collection agency you'll be assessed a $100 collection fee. This will be added to your final balance as it is placed with a collection agency. You will be responsible for all legal fees and court costs involved.If you present a check to us that is not honored by your bank, a $25.00 Non-Sufficient Funds charge will be added to your account per occurrence.

If you are unable to keep your appointment, please cancel within 24 hours by calling the office in order to avoid a $65.00 fee. Monday appointments need to be cancelled by Friday (24 business hours). After 3 consecutive “no-show” appointments or cancellations within the 24 hours of your appointment, you may be terminated from our practice.

Your signature on this authorizes us to release health information to insurance carriers when necessary for payment, and directs them to remit payment to us, which constitutes an assignment of benefits.

We may speak with the following person regarding your medical health care and medical records:

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NAME OF PERSONRELATIONSHIP TO YOUPHONE NUMBER

We may leave a detailed message on ______--______--______regarding your medical results or bill.

I understand that I can revoke this consent in writing, at any time; otherwise it will remain in effect.

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