Financial Policy and Agreement Form

INSURANCE BILLING
Your insurance policy is a contract between you and your health insurance company. We are not a party to that contract. It is your responsibility to know your benefits and how they will apply to the treatment you receive. If your insurance company has not paid your account in full within 60 days, the balance will be transferred to you and/or the guarantor listed on the Patient information form. All patients are responsible for their co-payment, co-insurance, unmet deductible and cost of non-covered services at time of visit.

CONTRACTED HMO PLANS
All co-pays must be satisfied at every visit. Due to contractual and uniform compliance issues with your insurance company, there are no exceptions to the policy of collecting co-pays at every visit.

CONTRACTED PPO PLANS
We will bill your insurance company as a courtesy. All co-pays, co-insurance, unmet deductible, and cost of non-covered services will be collected at the time of the visit. Any remaining balances due after contract adjustments and health plan payments are your responsibility. You will receive a statement for this remaining financial responsibility. All patient balances are due within 30 days of our statement date.

OUT OF NETWORK PLANS
For patients with plans that we are Out of Network. All services must be paid in full at the time of the visit/treatment. Our offices will provide you with an estimate of the cost of treatment before the visit.

CASH PATIENTS
For cash patients. All services must be paid in full at time of visit/treatment. Our offices will provide you with an estimate of the cost of treatment before the visit.

PAST DUE ACCOUNT BALANCES
Patients with an outstanding balance deemed past due (90 days) must plan for payment prior to scheduling any future appointments. Should your account become seriously past due, it will affect scheduling of any new appointments and refill of medications in a timely manner.

SUSPENDED ACCOUNTS AND TERMINATION OF CARE:
In the event outstanding balances are not paid within 120 days, your patient status will be suspended. Once suspended, your provider/patient relationship with the medical group will be terminated, and you will need to receive care and necessary medication refills elsewhere.

REPORTING OF DELINQUENT ACCOUNTS TO CREDIT AGENCIES:
If a patient account balance becomes delinquent and the patient account is suspended, that delinquent balance will be reported to national credit agencies. This may affect your current and long term credit status adversely. These delinquent balances will remain in affect with these credit bureaus indefinitely in the future until your overdue balance is paid.

PATIENT REFUNDS
The following criteria must be met prior to issuing a patient refund:
No outstanding insurance claims on the patient account.
No outstanding patient balance on the patient account.