Fill and Sign the Financial Policy for Physicians Office Form

Financial Policy for Physician's Office We are dedicated to providing the best possible care for you, and we want you to completely understand our payment policies. 1. Insurance We participate in most insurance plans, including Medicare. If you are insured by a plan we do business with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. 2. Co-payments and Deductibles All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. For your convenience we accept (list of names of credit cards) ________________________________________________________ ____________________________________________________________________________. 3. Non-Covered Services Please be aware that some and perhaps all of the services you receive may be non- covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit. 4. Proof of Insurance All patients must complete our patient registration form before having an exam. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in time to meet your insurance company claim filing limit, you will be responsible for the balance of the claim. 5. Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. 6. Coverage Changes If your insurance changes, please notify us so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in ( number of days) ______ days, the balance will automatically be billed to you. 7. Non-Payment. If your account is over _____ (number) days past due, you will receive a letter stating that you have _____ (number) days to pay your account in full, Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. You and immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have _____ (number) days to find alternative medical care. Our practice is committed to providing the best treatment to our patients. Our fees are representative of the usual and customary charges for our area. Let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines. Dated: _____________________ _________________________________ (Name of Patient) _________________________________ (Signature of Patient)