T.T.CHANNAPATI, MD AND ASSOCIATES
OUR FINANCIAL POLICY
Thank you for choosing Dr. Channapati and Dr. Balestrino as your healthcare provider. We are committed to providing you excellent healthcare. Our office staff will work very hard to make sure your paper work is filed accurately and promptly.
INSURANCE AND INSURANCE COLLECTION
The following are some of our provider’s guidelines with a few of the most popular insurance carriers.
HMO PLANS: Your insurance plan requires us to collect a co pay at each visit. We ask that you are prepared to pay at the time of your visit. If payment cannot be made at the time of the appointment, we ask that you reschedule your appointment.
PPO PLANS: We have agreed to accept the discounted rate from your plan, however all coinsurance is your responsibility.
Commercial Insurance: We will bill your insurance as a courtesy. However, after a period of SIXTY days with no payment made from the insurance company, the balance will be the patient’s responsibility.
Medicare: As a participating provider, we will bill your Medicare carrier. You are responsible for the early deductible and the 20% that is not covered by Medicare.
Secondary Insurance: Having more than one insurer does not necessarily mean that your services are covered 100%. We will bill your secondary carrier as a courtesy. You are responsible for any balance after your insurance has cleared.
Minor Patients: The adult accompanying a minor and the parents or guardians of the minor are responsible for payment.
Interest and Billing Fees: Any balance due from the patient must be paid within 30 days unless the office is called and a payment plan is set up. An account will get a final notice after 60 days, as a courtesy. If no response is made after that, the account will be sent to a collection agency.
Self-Pay Patients: All self-pay patients must pay for the first visit in full the day of the visit. Payments can be made on any balance when a procedure is preformed, this must be arranged with the office billing staff.
NO SHOW/CANCELLATIONS-Failure to cancel an appointment 24 hours in advance will result in a $25.00 charge.
Co-payments: A $5.00 charge will be added to your account for failure to pay your copayment at the time services are provided
Thank you for understanding our Financial Policy. Please let us know if you have any questions.
I have read the Financial Policy and I understand and agree with this arrangement.
______Signature of patient or responsible party Date Print Name