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OUR FINANCIAL POLICY
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.
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
• 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.
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 ½% 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__________