POLICY FOR
NON 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.

  1. We review your insurance card(s) at each visit.


  2. All charges for services rendered with our practice are due at the time of service. Patients will be provided with a form to submit to the insurance company for reimbursement. In the event of duplicate payment by the insurance carrier and the patient, the overpayment will be refunded. For those patients wanting CAPITOL EAR, NOSE & THROAT to file their insurance, there will be a $5.00 service charge.


  3. We will file your insurance for any surgeries.


  4. We strongly encourage you to contact your insurance carrier if you have not received an explanation of benefits within 45 days of your claim


  5. 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.


  6. 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).


  7. Missed or Late Cancellation of Appointments
    There is a $50.00 charge to the patient for a missed appointment or a cancellation within 24 hours of the appointment.


  8. Returned Check Fee
    There is a charge of $40.00 in the event of a returned check for insufficient funds.


  9. 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.

Patient Name:

Signature:

Date:

___________________________

___________________________

__________________________


It is our hope that the above financial policy will assist us in providing quality care to our patients. If you have any questions or need clarification of any of the above policies, please do not hesitate to speak with someone in our office.

Instructions:

  1. Print this form, then fax or mail it.
  2. Fax (919) 787-8841
  3. Mail Address West Raleigh Office
    3100 Blue Ridge Road, Suite 201
    Raleigh, NC 27612