All fees for medical care are based on the usual, reasonable and customary fee charged in this area by physicians of equal training and experience.
Payment for medical services rendered is due at the time of service unless prior arrangements have been made. All the forms have to be filled out in their entirety.
Our office verifies eligibility and benefits with your health insurance company. If we are unable to accomplish this you will be asked to pay for services rendered until we can confirm your status. We will do all we can to assist you with your insurance claims; however, insurance is a contract between you and your carrier. The patient/responsible party is liable for all co pays/coinsurance/calendar year deductible and non-covered supplies or services.
The exception to the above is for those patients with injuries that are work related and are covered by Worker’s Compensation. These patients are not responsible for their bills, unless their claim is denied. This is why we need information about your private insurance, so that the billing process can go smoothly if Worker’s Compensation denies your claim.
Prior authorizations obtained for procedures and therapy by this office on your behalf does not guarantee payment but rather based on medical necessity. Claims are subject to policy provisions and your insurance carrier determines final payment. A deposit is required if you are being schedule for surgery. If an assistant is required at the time of surgery to improve the quality of surgical outcome, the assistant’s fee is in addition to the surgeon’s fee. Furthermore, you will receive and will be obliged to satisfy bills from surgical centers, hospitals and anesthesiologists for surgical procedures independent of our office’s billing.
Having read the above, I hereby authorize payment by my insurance carrier, Medicare, Medigap, Veteran’s administration or other designated payer of medical benefits to HCON, for clinical, surgical, and/or therapy services furnished to me. This assignment will remain in effect until revoked by me in writing. I hereby accept financial responsibility for all charges incurred whether or not I have insurance coverage. A collection fee will be added to unpaid balances that are sent to collection agency. 1.5% interest accrued monthly. A photocopy of the assignment is considered as valid as the original. Any credit less than $20 will remain on your account unless requested by patient / responsible party. I authorize HCON, to release any information necessary, including medical records, to secure payment for services rendered to me.
I hereby consent to and authorize medical treatment, tests, procedures and/or therapy performed in the office that my physician deems advisable and necessary based on judgment. I understand that I may ask whatever questions needed to understand the necessity for and expected outcomes of the recommended care.
MISSED APPOINTMENTS
Because our practice is extremely busy, please help us to better serve you by keeping all scheduled appointments. We asked that you please cancel or reschedule any appointments you are unable to keep within 24 hours of the scheduled time. If you do not show for you appointment there is a $35.00 no show fee. If I miss or do not show to 3 of my appointments, I understand that I will be subject to being discharged as a patient.
COLLECTION POLICY
I agree to be financially responsible for all charges incurred regardless of insurance coverage. In the event my account is referred to a collection service due to lack of payment on my part, I agree to pay all collection/legal fees that may be added to my account. If referred to a collection service, I understand I will be subject to being discharged as a patient.
RETURNED CHECKS
There will be a $35.00 fee for all returned checks. If a check is returned, you will be expected to pay by cash, credit card, or money order all subsequent services.
DISABILITY PAPERS
There will be a charge of $35.00 per packet. Any subsequent disability form will be charged an additional $35.00 per packet. Paperwork can take up to 10 business days to complete. Payment is due at the time of form submission. Disability forms will be faxed 1 time with signed consent. I understand that it is my responsibility to pick up original forms.
PRESCRIPTION REQUESTS
Prescription request can take up to 48 business hours to complete from the time the patient has contacted the office.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. Our strict adherence to his policy services to enhance our provider/patient relationships.