Payment for office examinations and treatment is due at the time service is rendered unless you are covered by a health insurance plan with whom your healthcare provider is contracted or previous arrangements have been made with the office manager or billing department.
INSURANCE: Insurance is a contract between you and your insurance company. We are
a party to this contract, in most cases. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and reimbursment.
You agree to pay any portion of the charges not covered by insurance.
If your insurance company requires a referral and/or pre-authorization, you are responsible for obtaining it. Failure to obtain the referral and/or authorization may result in a lower payment from the insurance company leaving you with a higher balance.
Insurance is a method of reimbursing
, the patient, for fees you have paid to the doctor;
IT IS NOT A SUBSTITUTE FOR PAYMENT.
We are happy to assist you in submitting your insurance claims, however, in the event we have not received payment from your insurance plan within (45) days you will be responsible for the entire balance.
PAST DUE ACCOUNTS
: If we do not receive payment within (60) days yor account is considered past due. We refer past due accounts to a collections agency.
MISSED APPOINTMENT FEES
: We require a 24HR notice for cancellation and rescheduling of your appointment. Patients that cancel or reschedule with less than 24HR notice may be charged a fee of $50.00
RETURNED CHECK FEE
: There is a fee of $25.00 for all returned checks.
: We require authorization by your employer and/or your worker's compensation insurance carrier prior to your initial visit. If yourclaim is denied, you will be responsible for payment in full. Missed appointment fees are not covered by worker's compensation benefit; you are responsible for those charges.
Every 30 days you will receive a statement regarding any outstanding balance on your account. if you do not receive regular stament please contact our billing department.
Our goal is to communicate your financial obligations as clearly as possibl in order to focus more on your health care. Please notify is of any changes to your insurance coverage beofre your next visit. If you have any questions or concerns regarding your accountplease do not hesitate to contact our billing department.
I certify that the information I have provided on my registration form is accurate to the best of my knowledge. If the information I provided is not accurate I understand I may be billed for the balance and am liable for all charges for services rendered.
I have read the financial policy and understand that if i am not eligible under the terms of my Medical Insurance Agreement and/or Workers Compensation benefits, I am liable for all charged for services rendered.