Thank you for choosing us as your healthcare provider. We are committed to providing you with quality health care. Please read our payment policy, ask us any questions you may have, and sign in the space provided.
1. Insurance: We participate in most insurance plans, including Medicare. If you are uninsured or we do not accept your insurance plan, payment in full is expected at each visit. If your insurance card is not up to date, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
2. Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your copayment at each visit.
3. Non-covered services: Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.
4. Proof of insurance: All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance card/information. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
5. Claims submission: We will submit your claims you may be required to submit information directly to your insurance company. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are separate to that contract.
6. Coverage changes and coordination of benefits: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. It is your responsibility to ensure coordination of benefits are in place if you are covered by multiple insurance companies. If your insurance company does not pay your claim in 45 days, the balance will automatically be
billed to you.
7. Nonpayment: If your account is over 60 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may pass your account to a collection agency, and you may also be discharged from the practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our providers will only be able to treat you on an emergency basis.
8. Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will be your responsibility and billed directly to you. Please help us serve you better by keeping your regularly scheduled appointment.