FINANCIAL POLICY
SERVICES: Charges from Center for Women's Health (CFWH) are solely in relation to professional services rendered by a CFWH provider, and or other services that are performed in the CFWH clinic. All other services that require the patient to go elsewhere such as lab work, x-rays, MRI’s, CT’s, etc., are not included in the CFWH fee. Patient is responsible for all fees billed separately from the practicing location.
AMOUNT DUE: CFWH policy is to collect all patient responsibility amounts at the beginning of each appointment. Best efforts will be made to communicate the amount prior to the day of the appointment. However, some factors may change the amount due (ie personal insurance benefits, additional diagnosis or procedures). CFWH will kindly reschedule a patient appointment, if unable to remit co-payment or any past due balances. CFWH accepts cash and most major credit cards. Payment will include any unmet deductible, co-insurance, co-payment amount, and charges not covered by patient's insurance company. Inusrance is a contract between the patient and the insurance company and ultimately the patient is legally responsible for payment in full.
CLAIMS and BILLING AUTHORIZATION: As a courtesy to our patients, CFWH will file a claim for services provided with patient's carrier on file at the time of service. CFWH reserves the right to accept retroactive coverage at its own discretion. The patient is responsible for seeking reimbursement covered by retroactive coverage if not accepted by CFWH. This agreement authorizes CFWH to release requested medical information to patient's insurance company to collect payment for any charges incurred.
ASSIGNMENT OF BENEFITS
I hereby request payment of insurance benefits be made directly to Center for Women’s Health on my behalf for any services provided to me. I acknowledge and understand that I am financially responsible for all charges relating to the service(s) rendered to my dependent or myself. If, for any reason, my insurance carrier (including Medicaid) does not pay any portion of my bill within 60 days of submittal, the responsibility of payment transfers to me and I agree to pay promptly. Interest will accrue beginning 30 days after transfer of payment responsibility at a rate of 5% APR. CFWH reserves the right to refer any amounts due to a collection agency and at such time the agency fees will apply.
**IT IS YOUR RESPONSIBILITY TO BE AWARE OF YOUR INSURANCE BENEFITS.**
It is your responsibility to notify our office of any change to your insurance coverage, residence, or phone number. I have read and I understand the above FINANCIAL POLICY and I agree to abide by its terms.