All Patients must complete our Patient Information Sheet before seeing the doctor.
REGARDING MANAGED CARE INSURANCE WE PARTICIPATE WITH:
You are responsible to supply our staff with your identification cards and all referrals
And / or authorization forms PRIOR to seeing the doctor (if applicable). THERE WILL BE NO EXCEPTIONS.
If you do not have proper forms, I.D. cards or applicable co-pays as described in your insurance handbook, YOU MUST EITHER RESCHEDULE OR PAY FOR THE SERVICES IN FULL.
REGARDING NON-PARTICIPATING INSURANCE:
It is your responsibility to understand which insurance plans your doctor is participating with. The bill is your responsibility and is due at the time of service. Your insurance policy is a contract between
you and your insurance company. Our office is not part of that contract.
REGARDING NON-PARTICIPATING INSURANCE’S “USUAL AND CUSTOMARY RATES”:
Our practice is committed to providing the highest quality of treatment to our patients, and we charge what is usual and customary for our areas. You are responsible for payment regardless of any insurance
company’s arbitrary determination of usual and customary rates.
REGARDING SECONDARY INSURANCE:
We are not responsible for submitting balances to your secondary insurance companies. We will gladly provide you the information you need to collect from your secondary insurance carrier.
RETURNED CHECK FEE: $50.00
Thank you for understanding our office financial policy. Please feel free to let our billing office know if you have any questions or concerns or if you need to discuss payment arrangements.
I have read the above office financial policy, I agree and understand its terms.