Thank you for choosing Michigan ENT & Allergy Specialists as your health care provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to ourprofessional relationship. Please understand that payment for services is part of that relationship.
Insurance: We participate with most insurance companies, but not all. Insurance is a legal contract between you and your insurance company. We are not a part of that contract. Michigan ENT & Allergy Specialists will file claims to your insurance as a courtesy only and such courtesy may be withdrawn at any time. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance as well as any change of insurance information.Failure to provide complete insurance information may result in patient responsibility for the entire bill.
Cost Estimates: Upon your request, we will assist you to the best of our ability with prior authorizations, cost estimates and benefit inquires. Although we estimate what your insurance may pay, it is the insurance company that makes the final determination of your eligibility and benefits. We will relay this information to you as it is relayed to us. It is ultimately the patient’s responsibility to call your insurance company to find out what your schedule of benefits allows such as Deductibles, Coinsurances, Copays and Non-covered.
Please be aware that our providers may need to perform a diagnostic or other type of procedure during your visit. Many insurance companies categorize office procedures as “surgery” and apply the charges to the deductible instead of the office visit co-pay.
Payment: You are expected to pay your copay at every visit. If you do not have insurance, you may be required to pay in full or reschedule your appointment. Payment arrangements may be made by speaking with our billing staff. We accept cash, personal checks, Visa, MasterCard, American Express, Discover and Care credit. In the event that your account becomes delinquent and is +forwarded to an outside collection agency, you will be responsible for all reasonable collection and attorney fees required to collect any delinquent balance. For all services rendered to minor patients, we will look to the accompanying adult for payment.
No-show, Cancellation, & Late Arrival: I agree to adhere to informing Michigan ENT & Allergy Specialists of a need to cancel or reschedule an appointment 24 hours in advance, with the exception of an emergency, so they can best serve their patients. If I do not cancel my appointment in time or if I do not show for my scheduled appointment a fee may be applicable. Repeated offenses are cause for dismissal. If I arrive later than 10 minutes after my scheduled appointment, I understand I may not be able to be seen and may have to reschedule my appointment.
Fees: There will be a $25 service charge for all returned checks
Refunds: Patient/guarantor credits in amounts less than $10 will be retained on current patient accounts. The credit will be used toward future balances unless you request a refund. Credits greater that $10 will automatically be refunded to the patient.
FMLA/Disability: A $25 administrative fee will be charged for completion of these forms. This process may take up to 2 weeks to complete.
I have read and understand that I am financially responsible for all services provided to me, all amounts unpaid or not authorized by my insurance company and any cost of collection incurred by Michigan ENT & Allergy Specialists.
I authorize the release of medical information necessary to process my insurance claims.
I hereby authorize the personnel of Michigan ENT & Allergy Specialists and members of its medical staff to treat as necessary and appropriate.