| Office Financial Policy |
We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. Below we describe the financial policies and we outline some suggestions to help expedite the handling of potential insurance issues. Insurance Billing Please present your insurance card at each visit. As a courtesy to you, we will bill your primary insurance company directly for medical services rendered. Keep in mind that your insurance policy is a contract between you and your insurance company. If problems arise regarding coverage issues, we will work with you and your insurance company to help resolve them. However, please be advised that you are nevertheless ultimately financially responsible for payment of medical services rendered by this clinic. If you have medical coverage under two different medical insurance policies, including one provided by your employer, California law requires that you seek primary coverage under the insurance policy provided to you by your employer. If you prefer to seek coverage under the other insurance policy, you must first drop the primary insurance provided by your employer. Please be advised that this clinic only provides courtesy billing of your primary medical insurance company. We do not provide the service of billing secondary medical insurance policies. Co-payments A co-payment for each clinic visit may be required, as determined by your coverage under your medical insurance policy. Payment is due at time of service. We accept payment in cash, Visa or MasterCard. If you are entitled to reimbursement for such co-payments under the secondary medical insurance policies, it is your responsibility to collect these yourself. Non-covered Services Not all insurance plans cover all services. In the event, your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a statement from the billing department. Payment at time of service is required for the following:
Miscellaneous Service Charges The California Health & Safety Code and California Business & Profession Code state that Medical Offices may assess reasonable charges for the following:
I have read and understand Dr. Washington’s practice financial policies and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time. _________________________________________________ __________________ Signature of patient (or responsible party, if minor) Date
Please print the name of the patient _____________________________________________________________ |