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POLICY FOR CONTRACTED INSURANCE COMPANIES
Print this form then fax or mail it (See below).
In order to better serve your needs and clarify any questions that you may have regarding your insurance, we have adopted the following financial policy. If you have any questions, please speak with one of the members of our billing office, and they will gladly assist you.
- We will gladly file your insurance claim. Copays,deductibles, and co-insurance amounts are collected at the time of service. Any durable medical supply like hearing aids are not included in our contract and will be an out of pocket expense.
- We will review your insurance card(s) at each visit. All insurance changes must be given to us at the time of service. If your insurance changes, and we are not notified, you will be responsible for all charges. We will not bill your insurance for any charges before the change notification.
- As a courtesy to you, insurance forms for services rendered will be completed by our office with your primary insurance carrier. We will not file the secondary insurance, unless
- it is with a contracted insurance carrier, or
- they are for surgeries.
- We do not file Medicaid as a secondary insurance unless Medicare is primary.
- We strongly encourage you to contact your insurance carrier if you have not received an explanation of benefits within 45 days of your claim.
- For those patients who are members of an HMO or POS insurance plan etc., it is the patient's responsibility to get a current authorization from their primary care physician. Please verify with the receptionist before your visit that you have a current authorization. If you have no authorization, you will be responsible for visit charges at the time of service.
- The responsibility for payment for services rendered to any dependent children whose parents are legally separated or divorced, rests with the parent who seek treatment. Any court ordered responsibility judgment must be determined between the individuals involved without the inclusion of our office.
- In the event your health insurance plan determines a service to be "not covered", you will be responsible for the charge.
- Any supplies that you receive from our office must be paid in full at the time of service. (Examples: disability forms, sinus irrigation kit, Blom Singer, nasal irrigator, nasal adaptor, ear wick, Surgicel, injections, and hearing aids). Insurance companies do not cover miscellaneous supplies or administrative work.
- Completion of Forms
There is a $15.00 fee for completion of forms from your prescription drug plan. (We provide written prescriptions at the time of service at no charge). Payment for completion of these forms is expected before the form is completed by the physician.
Disability forms, FMLA forms, Leave of Absence forms, letters regarding airline tickets or travel and/or any requested correspondence that is not associated with reimbursement of a claim will be a $40.00 fee to the patient prior to completion of the form(s).
- Missed or Late Cancellation of Appointments
There is a $50.00 charge to the patient for a missed appointment without cancellation notice within 24 hours of the appointment.
- Returned Check Fee
There is a charge of $40.00 in the event of a returned check for insufficient funds.
- Statement Procedure
We will mail a "statement" to the address you have provided once we receive payment from your insurance carrier. In the event that payment is not received from you within 30 days, a second "past due statement" will be mailed. If we still do not have payment within 30 more days, we will make every effort to notify you that the account is being turned over to Equifax and will impact your credit rating.
Authorization
I agree to my financial responsibility to Capitol Ear, Nose & Throat for services rendered. I have read and understand the financial policy.
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