Financial Policy

PLEASE INITIAL THE LINES BELOW:

Type a label   PAYMENT: Payment in full is expected at the time of your visit. We accept cash, check and most major credit cards. Payment includes any co-payments, co-insurance or services not covered by your insurance. If you do not have any insurance coverage, payment IN FULL is expected at the time of each visit. Telehealth visits will be billed and payment is due upon receipt.

Type a label   BALANCE: If a balance on your account reaches 90 days past due there will be a $50.00 late fee added to your account.

Type a label   INSURANCE: Grapevine Women’s Health & Gynecology participates with most health plans, as a courtesy we file claims on your behalf. Your insurance is a contract between you and your health plan and you are ultimately responsible. Grapevine is not responsible to ensure contract status with your insurance plan. It is important for you to understand your insurance benefits. We recommend calling your insurance. If your health plan determines that a service is “non-covered” you acknowledge responsibility for charge. 

Type a label   LATE CANCELS & MISSED APPOINTMENTS: In Order to serve all of our patients, Grapevine Women’s Health & Gynecology requires cancellation 24 BUSINESS hours prior to your scheduled appointment. Failure to cancel your appointment or procedure at least 24 hours prior, will be subject to a $75.00 missed appointment or $125.00 for missed procedures. If you are more than 15 minutes late, we may need to reschedule your appointment.

Type a label   COLLECTION FEES: In the event your account is placed in a collection status, Grapevine Women’s Health & Gynecology will charge you a $100.00 fee. Additional fees would then be possible. Such as collections agency fees, attorney fees, court costs, interest and fines.

Type a label   RETURNED CHECKS: In the event a check is provided as payment and is returned by your financial institution, Grapevine Women’s Health& Gynecology will charge a $50.00 fee for each occurrence.
 
I have read and understand Grapevines Women’s Health & Gynecology’s Patient Financial Policy and agree to the terms. I also understand and agree that these terms may be amended by the Practice from time to time.