|
We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at anytime. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy or your responsibility.
|
 |
|
YOUR RESPONSIBILITIES AS A PATIENT
|
|
|
All patients must complete our "Patient Information Form" before seeing the doctor. It is the patient's responsibility to inform us of any changes in this information including: address, telephone numbers, employment, insurance coverage, etc., and we will ask to make a copy of your insurance card each time you visit our office.
|
|
|
FULL PAYMENT IS DUE AT TIME OF SERVICE.
|
|
|
CO-PAYMENTS ARE DUE AT TIME OF SERVICE.
|
|
|
WE ACCEPT CASH, CHECKS, AND VISA/MASTERCARD. THERE IS A $25 FEE FOR ALL RETURNED CHECKS.
|
|
|
PATIENTS WHO DO NOT SHOW FOR AN APPOINTMENT WILL BE CHARGED $25.
|
|
|
THERE IS A $25 CHARGE FOR EACH DISABILITY FORM.
|
|
|
In compliance with Texas Laws, the practice will send a copy of your medical records to other physicians with your consent. There is a copy service fee of $25 for the first twenty pages and .50 for every page after.
|
|
|
You are responsible for the timely payment of your account. We realize that temporary financial problems may arise, and, if this should happen, we encourage you to contact us promptly for assistance in the management of your account.
|
|
|
Large balances may be placed on a payment plan. Payments must be made on time and in full each month. Interest will be added monthly on all overdue accounts until the balance is paid in full.
|
|
|
Balances older than 30 days may be subject to additional collection fees and service charges.
|
|
|
REGARDING YOUR INSURANCE
|
|
|
If you have insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. You must realize, however, that:
|
|
| - |
Your insurance is a contract between you, your employer, and the insurance company. We are NOT a party to that contract.
|
|
| - |
Not all services are covered benefits in all contracts. Your employer selects and defines the services that are covered in your plan. You are responsible for paying for services not covered in your plan.
|
|
| - |
We will collect all portions of your bill which you are responsible for paying at the time of service.
|
|
|
|
We must emphasize that as medical providers, our relationship is with you, NOT your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are still your responsibility from the date the services are rendered.
|
|
|
FOR OUR OBSTETRICS AND SURGERY PATIENTS
|
|
|
We will contact your insurance company to attempt to determine what portion of your bill the insurance company is likely to pay, and what portion of your bill you must pay yourself. Please understand that insurance companies often will NOT give us accurate information on the exact dollar amount that they will pay for any given procedure. In addition, you may incur other costs such as sonograms (ultrasounds) and other tests and procedures which may or may not be covered by insurance, and which will affect your total bill. We will estimate the amount you are responsible for, which should be paid at the time of service, prior to delivery or surgery. Monthly payment arrangements are available for maternity patients.
|
|
|
We hope that this policy will clarify the relationships between you, your physician, your insurance and our office so that we can best serve your individual needs while you are a patient in our practice.
|
|
|
Responsible Party Signature
|
Date
|
|
|
