We are pleased that you have chosen our practice to serve your health care needs. The following is a statement of our financial policy. We ask you to read and sign below prior to any treatment.
Insurance Billing :
Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits and how they apply to your treatment. We bill your insurance as a courtesy to
you, but please be aware that not all services provided may be covered by your insurance plan. If your insurance company has not paid your account within 90 days the balance will be transferred to you. We accept CASH, CHECKS, VISA, MASTERCARD, and AMEX.
Cash patients
All services must be paid in full at the time of treatment
Administrative Fees
- All co-pays will be collected at the time of service, prior to seeing your provider. If co-payment is not made you will not be seen.
- All Medical Records requests are subject to a $25 preparation fee plus/minus shipping.
- A fee of $25 will be applied to all returned checks.
- Compensation, Employer Leave, and other forms. These forms will not be submitted until the fee is paid.
- A fee $25 dollars per form will be collected for completing all Disability. Worker's Compensation, Employer Leave, and other forms. These forms will not be submitted until the fee is paid.
- A fee of $35 will be charged for office visits cancelled without 24 hours advance notice.
OB Deposits
Before the end of your pregnancy, our billing office will verify your OB benefits and discuss your financial responsibility with you. Your balance is due within 30 days of delivery. You may make payments toward your obstetrical care before delivery to help prepare for any financial burdens.
Surgery Deposits
We charge only for professional services provided by the physician at our office. You may also receive a bill from the hospital, surgery center, anesthesiologist, assistant surgeon, or pathology department. They will bill your insurance directly. When your surgery is scheduled the scheduler will provide you with your estimated financial responsibility. This is usually 3-5 days prior to your surgery. The estimated responsibility will be collected as a deposit at the time of your pre-op appointment. If you cancel surgery with less than 24 hours notice your deposit will be nonrefundable.
I hereby attest that the insurance information I have provided is accurate and that I am an eligible member and understand that I am responsible for knowing my benefits. I will be financially responsible for all charges that are not covered by my insurance plan.