Office Financial Policy & Agreement:

The responsibility for payment of fees for services is direct obligation of the patient.

Your health benefit plan is an arrangement between you and the insurance company, HMO or your employer. While we will try to be helpful, and we may participate in the plan, your health benefit plan determines your coverage and any requirements for prior authorizations or referrals. We cannot know the benefits and exclusions of each patient’s policy. It is the patient’s responsibility to know and understand her coverage and benefits.

Billing your Insurance Carrier:
If you pay only a co-pay under a contractual agreement, the co-pay is required at the time of service. If you have a deductible, and it has not been met, we ask that you pay at time of service. We will still send the billing information to your insurance company for you. Some policies, even though we are in network with the insurance company, have a co-insurance. Payment of the patient’s portion is due at time of service. If not paid at time of service, you will receive an invoice for the portion that is your responsibility. If payment is not received from your insurer within 45 days, we will transfer the full balance to your responsibility.

Billing Information:
At each visit, please be sure we have your current demographic and insurance information. It is your responsibility to provide us with this information, and update it if it changes. You will be responsible for any charges billed to the wrong insurance carrier as a result of not providing accurate demographics or insurance information. We will not re-file a claim to the correct insurance after 30 days from the service date.

Non-Covered Charges
A non-covered service is any service that is denied by your insurance carrier due to benefit description or limitation, policy exclusions, or pre-existing waiting periods. Non-covered services will be the responsibility of the patient and payment is due at time of service.

Well Woman (Preventive) and Problem Focused exams:
A well woman exam is when a healthy patient is seen to screen for various illnesses and diseases; this is considered preventative. A problem visit is one where the patient has a specific concern, symptom or complaint. We are required to submit claims based on the services you receive. If we provide both a well woman and a problem focused exam, then other services may be billed. Depending on your insurance coverage, some or all of the cost may have to be billed to the patient. We recommend you contact your insurance carrier prior to each visit and inquire about the type of benefits you have. Once a claim has been submitted to your insurance carrier, the office will not change the coding in order to circumvent an insurance denial.

Bills from Laboratories, Hospitals and other healthcare providers:
If your medical care requires a pap smear, blood work, a culture, or a biopsy, the specimens are sent to an outside laboratory. When this occurs, you may receive a separate bill from that laboratory. This bill is in addition to, and separate from, your office charges. If you receive medical care during a hospital inpatient or outpatient encounter, you may receive separate bills from the hospital, the anesthesia department and other healthcare providers involved in your care. Any questions related to these bills cannot be answered by this office and will need to be directed to the billing entity.

No Health Insurance: : We require that you pay in full at time of service. Account balances past 60 days due may be subject to collection procedures.

Payment Options
We accept VISA, MC, Discover, Amex for payments above $50, and cash or local checks for all amounts. All NSF checks will be charged a $30 fee.

Past Due Accounts:
If your account becomes delinquent, the office will take necessary steps to collect this debt. We have options of sending your account to a collection agency or to an attorney, reporting your account to a credit reporting agency, or submitting a claim to the appropriate court. In the event your account is turned over to our collection agency, you will be responsible for all collection fees (33% will be added to your account balance) and all legal fees (court costs will be added to your balance) that our office incurs through the process utilized to collect the outstanding delinquent balance. If it is assigned to a collection service, you will be charged a 10% fee. Additionally, no appointments or services will be provided for non-emergent care, until the balance is paid in full.

Cancellation Policy:
Your appointment time is reserved for you. If you cannot keep your appointment, please contact our office so we can reserve that time for someone else. If you no-show for an appointment, or fail to provide 24 hours notice of cancellation, you will be charged $50. Cancellation fees are not covered by insurance.

Office Financial Policy & Agreement

Type Name as Digital Signature

Office Financial Policy & Agreement