Financial Policy

Payment for Service

I understand I am responsible for paying the full amount for all services on the day of service, unless the physician or Practice has an agreement with my insurance carrier. If I am insured, I authorize the Practice to release all information necessary to secure payment. I further understand my share of the cost of the services, e.g., co-payments, co-insurance, and deductibles, will be collected upon check-out.

Insurance Claims

As a courtesy, the Practice will file insurance claims with your insurance carrier. Your insurance company, in lieu of reimbursing you directly, will pay to the physician or Practice any benefits for services rendered. Your medical insurance carrier may pay less than the actual bill for services, so you may be responsible for payment of all services rendered. You are responsible for making available complete insurance information for accurate filing of claims. To meet this end, we will request your current insurance card at each visit. Reduction or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred. It is your responsibility to know and understand your medical insurance coverage. Not all services are a covered benefit in all contracts. Additionally, some services we provide will be billed separately for the office visit and may require a separate co-pay or be applied to your co-insurance/deductible. Please call your insurance company to verify your benefits. You will be responsible for all fees not paid by your insurance company.

Referrals and Authorizations

As a specialist, some insurance companies require that prior to any visit you must obtain an authorization or referral from your primary care physician. It is your responsibility to know if this is required by your insurance and, if so, to obtain the referral. If this is not done by the day of your appointment, you will be asked to either reschedule your appointment or pay the full amount for all services on the day of service. If your insurance company rejects a claim because a valid authorization or referral was not in place, the full cost of the visit will be your responsibility.

Financial Assistance

For patients with financial need, we offer payment plans. Please ask to speak with one of our financial representatives to discuss your options.

Scheduling Fees

If you are unable to keep your scheduled appointment, please contact our office at least 24 hours in advance. We reserve the right to charge for any appointment which is not cancelled with proper notice. A $50 fee will automatically be charged if you cancel your appointment with less than a 24 hour notice or no-show to your appointment. Please note your insuarnce company will not cover this charge.

Agreement

 I have read the above form and policies and agree to the terms stated.

Printed name________________________________________ Signature________________________________________

Date ___________________________________________