AMERITEK MEDICAL BILLING SERVICE,INC

Electronic Medical Billing and Full Practice Management

Form-Financial Policy

SAMPLE FORM: COPY, PASTE and EDIT

OUR FINANCIAL POLICY
We are committed to providing you with the best possible medical and patient support care. If you have medical insurance, we will try to help you receive your maximum allowable benefits. Please read the following, and complete the enclosed forms.
PAYMENT FOR SERVICES is due at the time services are rendered or upon receipt of patient billing statement. In order to expedite this payment we accept cash, personal checks and accept MASTERCARD or VISA.
We will do our best to verify that we can treat you. This is however, no guaranty of benefit. Any questions requiring your policy deductibles and co-pay refer to your insurance company.
INSURANCE: For many of you, your insurance is a contract between you and your employer or an insurance company, and we are not a party to that contract. For some of you, we are under contract with your employer or insurance company. For those patients whose plans list or accept OUR PRACTICE as a contract provider, we will submit the appropriate claim to your carrier. AFTER our office has received payment from your insurance company and all appropriate adjustments have been made, YOUR remaining balance will be billed to you and is then due and payable upon receipt of the bill. Be advised our services maybe Out of Network for your policy which could result in you having to meet an additional deductible.
MEDICARE: For those patients who are covered by Medicare, we will comply PATIENTS: with the law requiring physicians' offices to process insurance forms. AFTER our office has received payment from your insurance company and all appropriate adjustments have been made, YOUR remaining balance will be billed to you and is then due and payable upon receipt of the bill.
WORK COMP: OUR PRACTICE will submit the appropriate claim to your carrier. If your claim is denied you will be responsible for the entire balance. Your bill is then due and payable upon receipt.
AUTO CLAIMS: OUR PRACTICE will submit the appropriate claim to your carrier. If your claim is denied you will be responsible for the entire balance. If you are have an attorney represent you, a document from your attorney is required to be on file with the billing department before the 2nd visit.
RETURNED CHECKS: There is a $25 fee for all returned checks.
PAYMENT PLANS: If you believe you will need a payment plan, arrangements will need to be approved through our billing department prior to you balance exceeding $100.
BE ADVISED LATE FEES MAY BE APPLIED TO DELAYED PAYMENTS OF 1 % MO
If questions arise, please contact our billing department at 1-888-467-2425 for assistance. We consider financial matters important and ask you to bring any concerns to our attention.
Thank you for using us for your care.
I have read and understand this financial policy. Signature_______________________________ Date__________