MEDICATION REFILL POLICY: PLEASE CALL YOUR PHARMACY DIRECTLY FOR REFILLS. They will contact us for approval. Allow 48 hours to process your refill. Additional time may be needed should your insurance company require pre-authorization. We will file to your mail order pharmacy as a courtesy to you. It is the patient’s responsibility to keep the medication list current and notify us of any changes made by other physicians.
FINANCIAL POLICIES:
PAYMENT IS DUE AT THE TIME OF SERVICE. We accept cash, personal check, Visa and MasterCard. We require you to pay your estimated cost share at the time services are rendered. Any remaining balance will be billed to you once your insurance company has processed your claim. If any amount is left unpaid and collection fees are incurred, you agree to reimburse us the fees of any collection agency, which is based on a percentage of the balance, with a maximum of 3l% of the debt. Interest of 6% of the balance may also be charged and is your responsibility.
If you have insurance coverage, the insurance information must be supplied at the time of service. We will file up to 2 insurance claims, primary and secondary, as a courtesy for you. You are also responsible for any non- covered items or services. Not all services and supplies are covered by insurance. If you are not clear on the coverage and benefits of your plan, please call your insurance company to inquire what your out of pocket expenses will be for the services you receive. Your policy is between you and your insurance company and coverage varies per policy, we can not be involved in disputes over non-covered services or supplies. If your insurance has not paid our claim within 45 days from the date of service, we ask that you call your insurance company to expedite payment. After 60 days of non-payment, you will become responsible for the balance.
CANCELLATION POLICY: Please give 24 hour advanced notice if you are unable to keep an appointment so that we may open a slot for other patients in need. Failure to do this may resuh in a $25 cancellation fee.
PATIENTS WITH INSURANCE / RELEASE OF INFORMATION
I hereby authorize my insurance company to pay medical benefits directly to SMITHSON VALLEY FAMILY MEDICINE LLP. I authorize the release of any medical information necessary to process my medical claims to my insurance company. I agree to pay for any non-covered services or supplies.