Our objective is to provide you with the highest quality healthcare in the most cost-effective manner. However, the ability of our Practice to achieve this objective depends greatly on your understanding of our financial policy. If you have medical insurance, we will file insurance claim forms on your behalf. We do this as a courtesy to our patients and are anxious to help you receive the maximum allowable benefits from your insurer. Even though we will file insurance claims for you, we need your active participation in the insurance claims process.

MEDICARE PATIENTS:

NOTE: You will be informed of services not covered by Medicare prior to these services being rendered. Your signature upon the appropriate Medicare Waiver form represents your authorization for the physician to perform these services and your acceptance of the financial responsibility for these services.

Remember that your insurance contract is between you and your insurer. If your insurance company pays only part of your bill or rejects your claim, you are financially responsible for the balance and are to pay it upon receipt of your statement. If your claim remains unpaid by your carrier for more than 30 days from date of services provided, the balance will become your responsibility.

As the insurance industry changes, our office must make choices about with which plans to participate. Your plan may be one that covers certain areas with "out-of-network" benefits. These are usually Preferred Physician Organizations (PPO). Point of Service (POS) or indemnity plans cover a percentage of our fee based on the contract with your carrier. In some instances, your carrier will send a check directly to you, the patient, or the account guarantor rather than the provider’s office. Due to this, we offer several options for you to insure that your services are paid timely. 1) You may elect to pay your balance at or before the services are rendered and receive a 30% prompt pay discount. 2) If you prefer that we bill your insurance carrier, the full charge will have 30 days to be satisfied, with no discount (either from the check received by your insurance carrier or your own funds). If your balance is not paid within 30 days of services being rendered, your account may incur additional collection fees to satisfy the account balance.

Many HMO/Managed Care plans require that you obtain a referral in order to receive care from a specialist. It is your responsibility to obtain this referral if required. Unauthorized services will be the financial responsibility of the patient. Please have your referral forms and membership card available when you check in. You will be required to pay the co-pay for authorized services at the time of service. We will make every attempt to collect for our services with your insurance company, however, if your claim remains unpaid over 30 days from the date the services were rendered, the responsibility for payment will become yours.

Generally, patients with no insurance are required to pay for their visits at the time of service. If special financial arrangements are deemed necessary, you will be given information regarding who to contact at the time of your visit. It is imperative you follow these instructions immediately to satisfy your financial responsibility for services provided to you. There are two options for you: 1) You may elect to pay your balance at or before the services are rendered and receive a 30% prompt pay discount or, 2) If you prefer to be billed later, the full charge will have 30 days to be satisfied with no discount. If your balance is not paid within 30 days of services being rendered, your account may incur additional collection fees to satisfy the account balance.

We accept cash, personal check or Visa/Master Card as payment.

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Patient/Guarantor Signature                                         Date