Notice of Insurance Practices and of Patient Financial Responsibility

General Office Policies

Appointments.  When calling us for an appointment, please provide your name, date of birth, phone number, chief reason for visit, and any updated contact or insurance information. Please be on time.  Please bring your photo ID and insurance card (if relevant) and payment means to every appointment.

Appointment Notice and Cancellation Fee:  Company requires at least 24 hours advance notice prior to cancellation of any scheduled appointment.  If you miss your scheduled appointment, or cancel with less than the above advance notice, Company we will charge a cancellation fee equal to 50% of the fee associated with the visit to your credit card.  You hereby authorize this charge by providing the information below.

No Refunds.  Company does not offer any refund for office visits or services of any kind.

Online and phone communication; Electronic signatures. Company stores medical and office records digitally. While Company makes reasonable efforts to keep the data secure according to legal requirements, and maintains the privacy and confidentiality of patient data, I understand that no system is 100% secure. I agree that electronic signatures below are the legal equivalent of manual signatures on this Agreement, and manifest consent to be legally bound by this Agreement’s terms and conditions.

Office Insurance Practices and Patient Financial Responsibility

Payment: Company accepts debit and various credit cards.  Company bills to my debit or credit card on file unless you provide alternate payment information and instructions. Patient will have the option to pay post-service at Company’s hourly rate or in advance. 

No Participation in Insurance Plans: Company is an out-of-network provider for services within this practice; Company does not participate in any insurance panels, and does not accept assignment from any insurance company. Consequently, I am responsible for payment in full at time of service and charges are determined by Company.

No Responsibility To Determine Eligibility for Benefits: Company is not responsible for determining eligibility for benefits or for assisting me with collecting insurance benefits and has no responsibility to correspond with or telephone or email any insurer with which Company is an out-of-network provider.

My Financial Responsibility: Company may provide me with an itemized statement (or “super-bill”) to present to my insurance carrier.  However, I am financially responsible for any charges for services even should my insurer determine that those services are non-covered or are unreasonable, medically unnecessary or inappropriate. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Company to take action to secure payment of an outstanding balance.

Medicare: Company does NOT accept Medicare or Medicaid patients in this practice.  The patient is responsible for all charges.

Charges: In addition to the office consultation fee, Company may also charge me for specific services such as blood or urine tests, ultrasound, office surgical supplies and procedures, blood drawing and handling, and in-hospital services. Company often recommends testing through a specialty lab for information that cannot be tested through a conventional lab. This is one of the ways to dig more deeply into what may be causing or contributing to symptoms.  I understand that Company cannot guarantee that recommended lab testing (through a conventional lab or specialty lab) will be covered. It is my responsibility to check with my insurance company prior to getting any recommended lab work done to check on coverage.

Office Hours: Company does not offer urgent care or after-hours services. The patient will have direct access to Company via its patient portal which can be accessed 24 x 7.  Simple clinical questions and requests will be responded to within 2-5 business days.  Any inquiry that is more involved, may require scheduling a follow-up consultation.