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By accepting your insurance on assignment, we are extending credit to you. This courtesy may be withdrawn if circumstances below warrant. It is imperative that you understand these conditions and agree to them: Your insurance should pay within 30 days of your office visit. If your insurance has not paid within 60 days, then you will be responsible to pay the balance due. You will be reimbursed by our office when your insurance company pays the outstanding balance.
1. We will continue to bill your insurance as long as you are receiving active care in our office.
2.We require a valid credit card be kept on file with your account. This card will be charged in the event you are required to pay a coinsurance /deductible /additional copay per your policy.
3. Deductibles must be satisfied prior to assignment being enacted.
4. Copayment will be collected at time of service.
5. You are required to sign the informed consent, medical release forms, as well as any other assignment documents required by your insurance company.
6. Our office does not guarantee that your insurance company will pay. If, for any reason, your insurance claim is denied, you are responsible for the full amount of your balance. Any past due accounts are subject to a 3% monthly fee after 90 days. If an account is six months past due, it will be sent to collections.
7.Our office will not enter into a dispute with your insurance company over any claim. This is ultimately your responsibility and obligation.
8. Returned checks are subject to a $30.00 fee.
If you understand and agree with all of the above policies, please sign your name below, and we will accept your insurance assignment as stated above.
Appointments: We require separate visits for each problem due to time constraints. If your medical visit is greater than the allotted time, and/or there are complicated medical problems, we often add a prolonged visit code and/or an additional medical code. This may or may not be covered by your insurance. We realize your time is valuable, and you may not want to schedule another visit due to time constraints. However, we need to appropriately charge for the doctor's time.
Coding of Visits: In general, we will not re-code visits after the medical visit has been submitted to your insurance company.
Canceling an Appointment: Should you need to cancel an appointment, please give our office 24-hour notice (48 hours for Functional Medicine). Any appointment cancelled with less than 24-hour notice is subject to a $50 cancellation fee, which will be billed to the card on file. Failure to cancel/no show (you do not come in for your appointment) will result in the $50 cancellation fee. Three no show appointments and you will be discharged from the practice.
Telephone Calls: Our staff may handle brief questions, but in-depth questions will require an appointment with the doctor.
Labs: We use a third-party laboratory for our lab services. You are responsible for ensuring that HealthLabs through Northwestern Medicine out of Winfield, IL is in-network with your insurance. We do not handle the billing for HealthLabs. Should you have an issue with a lab bill, you will have to reach out to HealthLabs directly.
Acknowledgement: By signing below, you acknowledge that you have read, understood, and will abide by the policies and procedures of Ideal Health & Wellness.