PAYMENT is expected at the time of your visit. We will accept cash, check, debit card, credit card or care credit. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit. We do ask for a copy of your driver’s license and insurance card.
LATE CHARGES of $15.00 will be applied to all patient balances EVERY 30 days.
RETURNED CHECKS will incur a $25.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $25.00 service charge to pay the balance, prior to receiving services from our staff or the physician. Stopped payments constitute a breach of payment and are subject to the $25.00 service fee and collections action.
RESPONSIBILITY FOR PAYMENT: You are, personally, financially responsible for charges not covered by the assignment of insurance benefits. If your insurance company does not pay within 90 days of service, you are responsible for payment. Any subsequent insurance payments will be refunded to you. You are responsible for obtaining a properly dated referral/authorization if required by your insurer. You are responsible for payment if the claim is rejected due to lack of a proper referral or other circumstances indicated by your insurer.
COLLECTION FEES: In the event your account is placed in collection status, any additional fees incurred will be added to your outstanding balance. This includes, but is not limited to late fees, collections agency fees, court costs, interest and fines. These additional fees will be your personal responsibility to pay in full.
DIVORCED PARENTS of PATIENTS: By signing below, the adult who signs a minor child into our practice on the day of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment or communication. We will communicate about treatment and payment with the parent who signs in that day.
As a courtesy to you, we contacted your insurance company to get your benefits information. Their quotes are estimates only and are not a guarantee of payment. Any fees not paid by the insurance company are your responsibility.
I have read and understand the practice’s financial policy and I agree to be bound by its terms.
I also understand and agree that such terms may be amended at the practice’s discretion.
HIPAA Privacy Practices
Our Notice of Privacy provides information about how we may use and disclose protected health information about you. The Notice contains a section concerning Patient Rights under the law. The Notice is available to you at the front desk at your request. You may review the Notice before signing this consent. The patient has the right to restrict the uses of their information.
By signing this form, you acknowledge that you have read and understand our Notice of Privacy Practices and consent to our use and disclosure of protected health information about you for the purpose of treatment, coverage and payment from your health insurance company and overall health care operations. You have the right to revoke this consent in writing with your signature.