Thank You for choosing us as your primary care provider. We are committed to providing you with quality and affordable healthcare. The following information is provided to avoid any misunderstanding or disagreement regarding payment for professional services. Kindly read it, ask us any questions you may have, and sign it in the space provided. A copy will be provided to you upon request.
Please bring your insurance card at every visit. We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with, but don’t 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 including routine preventative care, acute care, and your co-payment.
Please be aware that some-and perhaps all- of the services or vaccines 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 visit.
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. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.
Failure to pay the remaining outstanding balance will be sent to an outside collection agency and you will be responsible for any fees (late fees, collection agency fees, court or attorney fees) associated with the collection of your outstanding balance. Partial payments will not be accepted unless otherwise negotiated.
There will be a $10.00 form processing fee for all forms brought into the office for completion by the provider. Disability form charges varies. We ask our patients to give us few days for completion of the forms with accuracy. Forms completed same day needed on urgent basis are charged a $20.00 processing fee.
Missed Appointments and No Shows
Our policy is to charge a “No Show Fee” of $25.00 for missed appointments not canceled within 24 hours prior to your appointment time. These charges will be your responsibility and billed directly to you. While we understand that circumstances do occur which may keep you from arriving on time for your appointment, we also have commitment to you as well as our other patients and that our providers have set aside their times in their schedule in order to meet your needs. We may ask you to reschedule your appointment time if you arrive 15 minutes late for your scheduled appointment depending on provider’s schedule. We ask our patients to kindly inform the office via telephone call or portal message at least 24 hours in advance of their appointment if you are unable to keep your scheduled appointment for that day.
We participate with Medicare. Patients are responsible for meeting their annual deductible and paying for the 20% co-insurance. We will file a claim with your secondary supplemental carriers. However, in the event that the secondary does not pay within 60 days; the patient may be billed.
Co-payments, Co-insurance and Deductibles
All copayments, coinsurances and deductibles must be paid at the time of your office visit. This arrangement is part of your contract with your insurance company. Any copays not paid at the time of service will be assessed a $10.00 fee.
Other Office Policy
Please bring your up-to-date insurance card at every office visit. All new patients must complete our patient information/registration forms packet before seeing the doctor. We must obtain a copy of your driver’s license and current valid health insurance card. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Also please notify office of any changes in your current address, phone number or pharmacy change at the time of your appointment.