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Patient Care Agreement Form
Our
goal is to maintain efficient patient account management in a cost effective manner.
Visa, MasterCard, Discover, American Express accepted
Pay your Bill Online
Patient Accounting Hours: 8am to 4pm Monday through Thursday
Financial Counseling Services:
Our financial counselors will provide you with benefit information, preauthorization of
services, personal financial responsibility information and budget payments.
Financial counseling services are open to all patients.
Financial counseling services are especially important if you are a surgical or
obstetrical patient.
Billing Services:
If we are in your health insurance booklet, a claim will be filed for you. Please
be prepared to furnish your healthcare card and pay your portion at the time services are
rendered.
If you have no healthcare coverage or coverage we do not participate with, please be
prepared to pay for your services at the time services are rendered. We will file
your claims as a courtesy to you and we will request that your insurance company pay you
directly. **If you do not wish us to file claims on your behalf, please inform the
checkout person.
We will assist you in any way possible to attain resolution from your insurance
company.
Statements:
You will receive a statement monthly when any activity takes place on your account.
You are requested to pay the patient portion listed on the statement upon receipt.
Refunds:
Refunds are issued twice monthly. Depending on when your overpayment occurs, your
refund should be issued within a 30-day time frame.
We stress that insurance coverage is a contract between you and your insurance
company. We are unable to determine if payment for your services will be made by
your insurance. The ultimate financial responsibility for services rests with you.
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