Patient Financial Policy. You must provide personal (address, phone numbers, etc) and/or insurance changes (carriers, networks, id numbers, etc) to the office at least 2 days prior to your appointment. In the event the office is not informed, you will be responsible for any charges denied. ____ Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with an assignment of benefits. You are agreeing to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. You are encouraged to contact your designated patient account representative at our office with any questions. ____ Please honor our 24 reschedule notice, as there may be a charge for appointments broken or cancelled without 24 hours advanced notice. Repetitive broken or cancelled appoints and/or non-compliance may result in transfer of your care to an alternative practice. ____ We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Any payment exceptions will be agreed upon in writing. ____ PAST DUE accounts are subject to collection proceedings including the credit bureau. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. ____ Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Hendersonville Podiatry Doctor- Patient relationship. ____ There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms of payment. Restitution of “Theft-by-Check” will be requested from the District Attorney’s Office. ____ Hendersonville Podiatry issues patient refund checks within 90 days of a completed investigation of the potential overpayment.
Patient Financial Policy. You must provide personal (address, phone number, etc.) and/or insurance changes (carriers, networks, ID numbers, etc.) to the office. In the event the office is not informed, you will be responsible for any charges denied. — You are responsible for all authorizations/referrals/prior authorizations needed to seek treatment with Obstetrics and Gynecology of North Texas physicians. If you are unsure, please check with a staff member. — Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with an assignment of benefits. You are agreeing to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. Please contact our office with any questions. — Please honor our 24hour reschedule notice, as there may be a charge for appointments broken or cancelled without 24 hours advanced notice. Repetitive broken or cancelled appointments may also result in a charge. — We have made prior arrangements with insurers and other health plans to accept assignment of benefits. We will xxxx those plans with which we have an agreement and will require you to pay the co-pay/co-insurance/deductible at the time of service. Your upfront portion will be calculated based on your insurance benefit/limits and our negotiated fee agreement with your carrier. If you are seeing our physicians on an “out-of-network” basis, you will be subject to out of network rates. Once the claims are processed by your insurance, there may be an additional balance. We will xxxx you for this amount. — Not all services are a “covered” benefit in all insurance policies; some plans even impose a waiting period before covering services. In the event your health plan determines a service to be “not covered/pre-existing,” or you do not have an authorization, you will be responsible for all charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their insurance carrier for clarification of benefits prior to services rendered. — Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you must notify our office of your designated primary policy. — Pre-schedu...
Patient Financial Policy. You must provide personal (address, phone numbers, etc) and/or insurance changes (carriers, networks, id numbers, etc) to the office at least 2 days prior to your appointment. In the event the office is not informed, you will be responsible for any charges denied. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with an assignment of benefits. You are agreeing to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. You are encouraged to contact your designated patient account representative at our office with any questions. Please honor our 24 reschedule notice, as there may be a charge for appointments broken or cancelled without 24 hours advanced notice. Repetitive broken or cancelled appoints and/or non-compliance may result in transfer of your care to an alternative practice. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. PAST DUE accounts are subject to collection proceedings including the credit bureau. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office.
