We firmly believe that a good doctor/patient relationship is based upon understanding and open communication. We hope to avoid any disagreement over payment for professional services by clearly defining our policies at the onset. If you have any questions concerning this policy or need any assistance with your account in the future, please contact us immediately.
Your insurance coverage is an agreement between you and your insurer. If your carrier fails to remit payment for your account, you will be responsible for contacting your insurance carrier. You are encouraged to contact your carrier prior to services to ensure you understand what your plan guidelines will cover for your visit.
Payment is due at the time of service. Patients presenting without insurance information are expected to pay for services in full at the time of service.
ALL patients will be asked to put a card on file for ease of payment after insurance has processed your claims. We recommend an FSA (Flexible Savings Account), HSA (Health Savings Account), or Credit Card. Debit Cards are also accepted. Accepted methods of payment include: Visa, MasterCard, Discover, and American Express. You
pay your bill online through our payment portal which can be accessed on our website at
under "Pay Bill"
If you do not have a card to put on file, estimated patient responsibility will be assessed and collected at the time of your appointment. Patients will receive a notification 5 days prior to any amount taken.
If provided insurance information, we will file claims with your insurance carrier. Once your insurance has processed your claim, you are responsible for any balance due. Credit Card on file will be charged for ONLY the amount insurance applies to patient responsibility. Patients are responsible for calling our office prior to a deduction being taken if there is a dispute with the charges applied by their insurance company. We will then put charges on hold until the dispute can be resolved.
1. INDIVIDUAL’S FINANCIAL RESPONSIBILITY
I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit. In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided. If I am uninsured, I agree to pay for the medical services rendered to me at time of service.
2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to (PROVIDER OR GROUP NAME) on my behalf for any services furnished to me by the providers.
3. AUTHORIZATION TO RELEASE RECORDS
I hereby authorize (PROVIDER OR GROUP NAME) to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.
3. MEDICARE REQUEST FOR PAYMENT
I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in (PROVIDER OR GROUP NAME). I authorize any holder of medical or other information about me to release to Medicare
and its agents any information needed to determine these benefits or benefits for related services.