FINANCIAL ARRANGEMENTS AND INSURANCE
We are committed to providing you with the best possible care. 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.
Payment for services is due at the time services are rendered. We accept cash, checks, MasterCard, Visa, Discover, We will be happy to process your insurance claim form for reimbursement. However, in order to do so, you must provide us with a copy of your insurance card. We also ask that you pay your portion at the time of service;
Returned checks and balances older than 90 days are subject to additional interest charges of 1.5% per month and professional collection procedures. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:
1) Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
2) Our fees are generally consldered1to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50% of "UCR". "UCR" is defined as usual, customary and reasonable by most companies. This statement does not apply to companies who reimburse based on an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in this area. .
3) Not all services are a covered benefit in all contracts. Some Insurance companies arbitrarily select certain services they will not cover.
We must emphasize that as hea1thcare providers, our relationshlp 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 your responsibilities from the date the services are rendered. We realize that temporary financra1 problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.
Accounts on which no payment is received for three billing cycles (90 days delinquent) will be subject to our collection procedure which may include turning the account over to a professional collection agency.
If you have any questions about the above Information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. We are here to help you.
I have printed an extra copy of this document and understand that the original will be kept. In my chart.
Patient/Parent's Signature__________________________________ Date_____________
Print Name __________________________