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OFFICE POLICY

Thank you for choosing our office as your 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 patient policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.Appointment Policy Office visits are scheduled according to the severity of your condition and the program of care that the doctor feels is best for you. Because your condition may require numerous appointments over the next few weeks or months, we have designed a Multiple Appointment Program for your convenience. This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine. The frequency of your visitation schedule is of paramount importance to your results, so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results. If, for any reason, you are unable to keep an appointment, we require that you telephone immediately to reschedule that visit. It is the patient's obligation to make up a missed appointment within 7 days of any cancellation. Also, this office reserves the right to charge for missed appointments and those appointments cancelled without 24 hours notice. When entering the office on any given visit, please go directly to the front desk and we will direct you to a room. We sincerely attempt to honor all appointments at the scheduled time. If you are late, you may be asked to wait for the next available appointment. If we are unexpectedly running behind, we will attempt to call you and advise you on the status of your appointment time. If you have any questions regarding our office policy or your appointments, please do not hesitate to ask.Financial Policy It is the policy of this office that all services rendered are charged directly to you, the patient, and ultimately the patient is responsible for all services, including those not reimbursed by third party payors. All payments are expected at the time of service, or at the end of each week based on agreement with the billing department in writing. Patient balances may not exceed $200 at anytime. All insurance assignment patients must pay their deductibles in full and the copayment at the time of service, or at the end of each week. Returned checks and balances over 30 days may be subject to additional collection fees and interest charges of 1.5% per month (pending state law for the maximum allowable rate). Charges may also be made for missed appointments and those cancelled without 24 hours notice. All accounts not paid within 30 days will automatically be put through your personal credit card for collection.

Insurance Assignment And Payment Policy 1. The privilege of insurance assignment begins when our office receives your insurance forms. 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. 2. All deductible payments MUST be made prior to insurance submittal. 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. 3. You are considered to be a cash patient until our office "qualifies" your coverage to determine the extent of benefits under your policy. 4. All co-payments are payable when service is rendered or at the end of each week. A $200 co-payment balance must not be exceeded by any patient. 5. This office does not file for or accept co-payment for secondary insurance coverage. 6. Should you discontinue care for any reason other than discharge by the doctor, any balances due will become immediately payable in full, regardless of any claims submitted. 7. This office does not promise that an insurance company will reimburse you for the usual and customary charges submitted by this office, nor will we enter in any dispute with an insurance company over the amount of reimbursement. 8. Since we do not own your policy and occasionally have trouble in collecting from the carrier, we may ask for your active assistance in rectifying this situation. 9. We offer a variety of payment options for your convenience. Please ask our office about the various options. 10. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visitor or time billed. 11. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. 12. Claims submission. 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. 13. 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. If your insurance company does not pay your claim in 30 days, the balance will automatically be billed to you. 14. Nonpayment. If your account is over 30 days past due, you will be notified that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified 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. 15. Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will 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. Our office cannot promise that your insurance company will reimburse all provided services or pay what is reasonable and customary. 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: Patient Signature or responsible party and Date:_________________________________