Patient Responsibility: Patient understands that it is his/her obligation to know his/her insurance requirements and ensure that they have been fulfilled, including having a valid authorization for service in place prior to his/her Medical services South Pointe Healthcare will check for eligibility as a courtesy, however this is not a guarantee of payment/coverage by the insurance company. Insurances that fail to pay for claims filed, regardless of the reasoning, will lead to the Patient and/or Guarantor being responsible for payment of the remaining uncovered charges. Insurance has to be present and active at the time of service, along with a valid U.S issued photo identification. If insurance information is presented after treatment we will file a claim to your insurance company on your behalf. However, you will be held liable for the charges if the insurance denies the claim because of late presentation of coverage or for lack of timely authorization due to late presentation of coverage.
Insurance Payments: We participate with most insurance plans in the area. Some services may not be covered by your insurance policy. Your insurance coverage is a contract between you and your insurance plan. Co-payment, deductibles, co-insurances and services are not covered by your insurance plan or outstanding balances are all patient's responsibility to pay in full.
Co-Payments are due at the time of service: It is your contractual obligation with you insurance company to pay the copay portion of the visit at time of service. Patients unable to pay their copay, will have their appointment rescheduled.
Missed Appointments: We charge a $50.00 fee for any office appointments missed or cancelled under 24 hour's notice. Late appointments and same day reschedules are considered missed appointments and are subjected to a missed appointment fee. These fees are patient responsibility and will not be submitted through insurance or liens.
Medical Records: We offer patient free electronic records via a secure email. You will be subjected to a fee for any printed records. We wll fax all records for free to any Physician's office or other medical facility as a courtesy. A signed HIPAA authorization will be required to send your records to any third party requester.
Past Due Balances: After 90 days your account will be considered past due and can be turned over to a third-party collection agency. If it becomes necessary to turn your account over to a third-party collection agency due to your non-payment you will be dismissed from the practice. We ask that you handle any outstanding balances within 90 days. Please reach out to our billing department or Practice Manager for needed payment arrangements.
Self-Pay: Patients who are not billing a third party or health insurance must pay in full at the time of service.
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I have read and agree to the above policies and authorize payment directly to South Pointe Healthcare.