FINANCIAL POLICY

Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read this carefully and if you have any questions, please do not hesitate to ask a member of our staff.

 

1. On arrival, please sign in at the front desk and present your current insurance card. IF THE
INSURANCE COMPANY THAT YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT
OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.


2. According to your insurance plan, you are responsible for any and all co-payments, deductibles,
and co-insurances.


3. It is your responsibility to understand your benefit plan. It is your responsibility to know if a
written referral or authorization is required to see specialists, if preauthorization is required
prior to a procedure, and what services are covered.


4. If our physicians do not participate in your insurance plan, payment in full is expected from you
at the time of your office visit. For scheduled appointments, prior balances must be paid
prior to the visit, you will be asked to re-schedule.


5. If you have no insurance, payment for an office visit must paid at the time of the visit
or you will be asked to reschedule.


6. Co-payments are due at the time of service or you will be asked to reschedule.
7. Statements are sent out at the end of the month. Your remittance is due within 10 business days
of your receipt of your bill.


8. If previous arrangements have not been made with our finance office, we request that
you notify our office 72 hours before your scheduled appointment time to discuss
your account with our finance person, or you will be asked to reschedule.


9. We require a 24-hour notice for canceling any appointments. There is a $35.00 fee for office
visits and a $50.00 fee for PFT visits if they are not canceled OR if a 24-hour notice is not given.
There is a $250.00 fee for sleep studies if not canceled within 72-hours (3 business days)

10. A $45.00 fee will be charged for any checks returned for insufficient funds, in addition to any
bank fees incurred.

11. Not all services provided by our office are covered by every insurance plan. Any service
determined to not be covered by your plan will be your responsibility.
I have read and understand this office financial policy and agree to comply and accept the responsibility
for any payment that becomes due as outlined previously.