Premier Surgical Associates, PLLC
All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.
Financial Responsibility (Financial Policy is available in office UPON REQUEST)
I understand and commit to the following:
1. I have recieved a copy of Premier Surgical's financial policies and have read and understand these policies.
2. I will pay my cop-pay, deductible and co-insurance at the time of service.
3. I will provide the most current insurance information and immediately notify Premier Surgical of changes.
4. I surgery is required, all or a portion of my financial financial responsibility must be paid prior to surgery.
5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances.
6. I understand that I am responsible for all balances after insurance has paid.
7. If I have no insurance, I have informed Premier Surgical and I am responsible for 100% of all balances.
8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.