Financial Payment Policy The purpose of this form is to notify you of our office policy in advance. Please read this carefully and if you have any questions, do not hesitate to ask a member of our staff.
Our office participates with many managed care insurance companies. Should your insurance coverage be with one of these companies, we will bill your insurance company along the guidelines of our contract. Co-payments, co-insurances, deductibles, and non-covered services that have not been satisfied, are the responsibility of the patient. Payment is expected at the time services are rendered.
There are times when making a payment can be a financial hardship. Please advise our staff prior to your visit if you are in need of a special payment arrangement. Co-pays are exempt from this because your insurance requires you to pay your co-pay at the time services are rendered.
You are required to notify us at the time of service if this is a visit due to a motor vehicle accident — MVA's must be filed with your automobile insurance company. Please have your auto insurance card available with the claim # from your insurance agent.
If we are your primary care physician, make sure our name and/or phone number appears on your card. If your insurance company has not been informed that we are your primary care physicians as of this date, you will be financially responsible for the visit.
Before making an annual physical appointment, check with your insurance company. Not all plans cover annual healthy physicals or hearing and vision screenings. It is YOUR responsibility to know your insurance plan benefits. If it is not covered, you will be responsible for payment at the time of visit.
Not all services provided by our office are covered by every plan. Any service determined "not covered" by your plan will be your responsibility.
Patient balances are billed immediately upon receipt of your insurance plan's explanation of benefits. Your remittance is due within 30 business days of your receipt of your bill. Unpaid balances may result in the postponement of scheduled well visits. Any balance over 120 days will be forwarded to our collection agency.
A $25.00 fee will be charged for checks returned for insufficient funds. If a check is returned, all future payments must be cash or credit.
We charge $5.00 to transfer medical records to cover mailing fees. If you would like to pick up medical records, there is no charge. Please give 7 working days to have medical records ready for release.
If your child has school, camp, or sport forms to be completed, there is a 3-5 day turnaround time |
