Thank you for choosing us as your health care provider. We are committed to your successful treatment.
The following is a statement of our Financial Policy that all patients are required to read and sign prior to any treatment being given.
Unless you are a member of one of our contracted insurance plans, or Medicare, full payment is due at the time of service. We accept most major credit cards.
If the physician is contracted with your plan, the majority of members covered under this type of plan are still required to make some type of payment for service that is rendered to them. This may be in the form of co-payment, deductible or co-insurance. If your plan has a co-payment, you will be expected to pay your co-payment prior to being seen by the doctor. Co-payments, deductibles and co-insurance are requirements of your insurance plan and we are required under our contract with these plans to collect these amounts from you.
POS AND HMO PLANS
Most of the members covered under POS and HMO plans also owe co-payments, and members of POS plans my also owe deductibles and/or co-insurance. Co-payments will be collected prior to being seen by the doctor. You will be billed for co-insurance and deductible amounts. We are required under our contract with these plans to collect these amounts from you.
BALANCES ON ACCOUNT
All previous balances are to be paid in full prior to additional services being rendered.
In the event that your insurance company has paid their portion and the balance remaining is your financial responsibility, we expect that you will pay any co-insurance, deductibles, or any other balance in a timely manner. Should your payment fail to reach us prior to the generation of a second billing settlement to you, a re-billing charge of $10.00 will be added to your total balance due. This amount will be added to your balance each month until your account is paid in full. For your convenience, we accept credit card payments by phone.
Should it become necessary for us to utilize the services of an outside collection agency in order to collect the amounts due and owed by you under the terms of your insurance coverage, you will be held liable for any and all collection agency fees and/or attorney fees which will be approximately 21% over and above the actual charges for services which were rendered to you. Further information that is helpful or necessary for collection purposes will be forwarded to our professional collection agency.
ASSIGNMENT OF BENEFITS AND MEDICAL RECORDS RELEASE
I hereby authorize my insurance benefits to be paid directly to the above signed physician realizing I am responsible to pay non-covered services and I hereby authorize the release of pertinent medical information to insurance carriers.
Thank you for reviewing our Financial Policy. Please let us know if you have any questions or concerns.
All patients are asked to sign the following statement after reading our financial policy:
I have read the Financial Policy and understand and agree to adhere to this Policy.