Billing and Insurance Policy

Billing Insurance & Payment for Services:
Please present your current health insurance card(s) at each office visit. Our office will bill validated Primary Insurance as a courtesy. You must pay for any patient responsibility. If you have No Insurance, then payment in full is required at the time of service. It is your responsibility to know your insurance.

Copays must be paid at the time of service. We mail statements each month. Payment is expected in full within 30 days unless other arrangements have been made. We accept cash, checks, money orders, Visa, MasterCard, American Express and debit cards.

Please initial that you understand our payment terms above.   Initial Here*   
 
Returned Checks:
The charge for a non-sufficient funds (NSF) check is $25.00. You must pay in full for the NSF check and NSF fee within 10 days of notice.
 
Collection Accounts:
When an account remains unpaid after 90 days, we reserve the option to refer the account to an outside collection agency. We reserve the right to reschedule or deny future appointments for delinquent accounts. If your account is sent to a collection agency you may be asked to find another provider.
 
Late Arrivals, Cancellations, and No Shows:

• Please arrive 15 minutes prior to your scheduled appointment to allow for timely check-in.
• We require a 24-hour notice to cancel or reschedule an appointment. (if not, it is considered a NO SHOW - see fees below).
• If you arrive 15 minutes late to your appointment you have missed your appointment; therefore, a late cancellation fee will be charged at our discretion.

 
Failure to show for appointment, or failure to give proper notice for cancellation/reschedule may result in:

• First time - $50.00 NO SHOW FEE
• Second time - $50.00 NO SHOW FEE
• Third time - Your family may be released from the practice.

 
Please initial that you understand the policy and fees above.   Initial Here*   
 
I acknowledge and understand the office policies and procedures explained above. I hereby authorize my insurance company to pay Family Medicine Associates directly. A copy of this authorization can be considered an original for insurance purposes.

I do hereby consent to and authorize the performance of all examinations, treatments, and medical services by Family Medicine Associates and their staff, which may be deemed advisable. My signature on this document indicates that I have read, understand, and agree to the policies outlined in this document.

I have read the Privacy Notice and understand my rights contained in the notice. By way of signature, I provide Family Medicine Associates with my authorization and consent to use and disclose my child’s protected health care information for the purposes of treatment, payment, and health care operations as described in the privacy notice.