Family Practice Partners Payment
Thank you for choosing us as your primary care provider. We
are committed to providing you with quality and affordable health care. Because
some of our patients have had questions regarding patient and insurance responsibility
for services rendered, we have been advised to develop this payment policy.
Please read it, ask us any questions you may have. A copy will be provided to you upon request.
1. Insurance. We
participate in most insurance plans, including Medicare. If you are not insured
by a plan we do business with, payment in full is expected at each visit. If
you are insured by a plan we do business 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. Please
contact your insurance company with any questions you may have regarding your
coverage. If your visit will clearly not
be covered by an insurance plan, and you pay for your visit at the time of your
service, you will be entitled to a discount for your prompt payment.
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.
Failure on our part to collect co-payments and deductibles from patients can be
considered fraud. Please help us in upholding the law by paying your co-payment
at each visit.
services. Please be aware that your doctor may consider a service necessary
for your care while your insurance company may not cover it���s cost. Some ��� and perhaps all ��� of the services you
receive on any given visit may be noncovered or not considered reasonable or
necessary by Medicare or other insurers. You must pay for these services in
full at the time of visit.
4. Proof of
insurance. All patients must complete or verify the correctness of our
patient information form before seeing the doctor. 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 a timely manner, you will
become responsible for the balance of a claim.
5. Claims submission.
As a courtesy to you, 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. If your
insurance company does not pay your claim in 90 days, the balance can be
considered to be your responsibility.
6. Coverage changes.
If your insurance changes, please notify us before your next visit so we can
make the appropriate changes to help you receive your maximum benefits. Failure to notify us may lead to providing services
that the insurance does not pay for and that will be your responsibility.
7. Nonpayment. If
your account is past due, you will receive a letter stating that you must pay
your account in full. Partial payments will not be accepted unless an active
payment plan is negotiated. Please be aware that if a balance remains unpaid,
you may be refused care until the balance is paid. Repeated episodes of failure to pay may lead
to your discharge from this practice. If this is to occur, you will be notified
by regular and certified mail that you have 30 days to find alternative medical
care. During that 30-day period, our physician will only be able to treat you
on an emergency basis. Such a dismissal
may also involve immediate family members receiving care at this practice.
We reserve the right to turn unpaid accounts over to a collection agency. Costs associated with this process will be your responsibility.
appointments. Our office needs to know what times are available to provide
care to those needing care. We reserve
the right to charge a fee for missed appointments not canceled within a
reasonable amount of time. These charges would be your responsibility and
billed directly to you. Please help us to serve you better by keeping your
regularly scheduled appointment.
Our practice is committed to providing the best treatment to
our patients. Our prices are representative of the usual and customary charges
for our area.
Thank you for understanding our payment policy. Please 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:
Signature of patient
or responsible party Date
End of box file