Teresa A. Marlino MD, LLC Patient Financial Policy

Your clear understanding of our patients’ financial responsibility is important to our professional relationship. Please understand that payment for services is part of that relationship. Please review the following Financial Policy, ask us any questions and sign in the space provided. A copy will be provided to you upon request.

INSURANCE ACCOUNTS We ask that you present your insurance card to us at every visit. If you fail to provide us with the correct insurance information at each visit, you may be responsible for payment for all services provided.

  • Copayments are due at the time of check-in. Waiver of copayment may constitute fraud under state and federal law. Please help us in upholding the law by paying your co-payment at each visit.
  • We are contracted with most insurance plans, but it is the patient’s responsibility to verify with your health insurance company that we are an in-network participating provider. If you are not insured by a plan we are contracted with, payment in full is expected at the time of service. If you are insured by a plan we are contracted with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.
  • We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request.
  • Routine services include but are not limited to physicals, pap tests and pelvic exams. Some insurances restrict routine or preventative medicine to one visit per year. If your insurance does not include routine benefits, you will be expected to pay the balance in full within 30 days of notification from our office that the bill is your responsibility. We cannot bill your visit any other way when you schedule an annual exam or have any service classified as routine. To do so would be fraudulent.
  • Your health insurance contract is between you and your insurance company. Knowing your insurance benefits is your responsibility. Any questions or complaints regarding your coverage should be directed to your insurance carrier.

ACCOUNT BALANCES Partial payments will not be accepted unless otherwise negotiated with our billing office.

FORMS COMPLETION Ouroffice charges $20 for the completion of disability, workers compensation, adoption and FMLA forms. These charges will be your responsibility and will be billed directly to you.

AUTHORIZATION I have read, understood and agree to the financial policy stated above and I accept responsibility for payment of all fees/charges incurred with Teresa A. Marlino MD, LLC.

Patient Name______Patient Date of Birth______

Patient/Responsible Party Signature______Date______