Welcome to the Medical Office of Roger W. Washington, MD.
 We are dedicated to providing the best possible care for you and we want you to completely understand our financial policies.

Insurance Billing
As a courtesy, we will bill your primary insurance company for medical services rendered. Your insurance policy is a contract between you and your insurance company.  If problems arise regarding coverage issues, we will work with you to help resolved them.  However, you are ultimately responsible for understanding what is covered under your policy and for payment of medical services rendered by this office.

If you have medical coverage with two different insurance policies, including one provided by your employer, California law requires that you seek primary coverage under the insurance policy provided by your employer.  This office 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 may be required for each office visit, as determined by your medical insurance policy.  Payment is due at the time of service.  We accept payment in the form of cash, VISA or MasterCard.  If you are entitled to reimbursement for such co-payments under a secondary insurance policy, it is your responsibility to process and collect this yourself.

Deductibles
If we determine that you have not met your annual deductible at the time of your service, we require a $50 payment. This will be applied towards the balance of your account. A refund may be issued once the claim has been paid and it has been determined an overpayment has occurred.

Non-Covered Services
It is ultimately your responsibility to understand your policy. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Not all procedures are covered. Our office will try to establish if such services are payable within your plan. 

Payment at time of service is required for the following:

• Non-covered charges: may include but are not limited to weight management and mental health
• Immigration Physicals
• Deductible Plans
• Lack of Medical Coverage

Miscellaneous Charges
The California Health and Safety Code, and California Business and Profession Code, state that Medical Offices may assess reasonable charges for the following:

• No Call/No Show appointments                       $50
• Same Day Cancellations                                   $50
• Medical Records search and/or Copy             $25 - $100 (depends research time)
• Attending Physician Statements                       $50
• Paperwork/forms                                                                 $25 and up (items such as DMV, school, sports etc)

I have read and understand Dr. Washington MD Practice Financial Policies and I agree to be bound by its terms.  I understand and agree that such terms may be amended by the practice from time to time.

___________________________________                                              _________________
Signature of Patient (or responsible party if under 18 years of age           Date

Please print patient name ______________________________________________________                                   rev 10/2010