The following sets forth the general billing policy of Victory Physicians and Frank Arian, M.D., Inc. Please review this information and sign where indicated.
- I understand that it is my responsibility to provide the office, Victory Physicians and Frank Arian, M.D., Inc. with current, accurate billing information at the time of check in and to notify the facility of any changes in this information.
- I understand that it is my responsibility to know my co-pay and to pay it prior to services being rendered. I understand that this is a contractual agreement that I have with my health plan and that the clinic also has a contractual agreement with my health plan to collect co-pays at the time of service, and we are required to report to the carrier any enrollees failing to pay the co-pay.
- I understand that if I present an insufficient funds check (NSF Check) for payment on my account, I will be charged a $35 NSF fee. I further understand that to rectify my account, I will be required to pay with cash, money order, cashier’s check or credit card.
- I understand that there is a $20 fee to complete disability paperwork associated with my care. I will be provided a standard form free of charge; however if additional disability forms (such as FMLA) require completion, I understand that the $20 fee (payable prior to completion) is required.
- For copies of records given to patients, or to another physician for transfer of care, a filing and clerical fee of $15 applies for a maximum of 10 pages plus postage. Each additional page is a fee of $0.25 per page.
- For records to attorneys or insurance companies, a filing and clerical fee of $25 applies plus postage. Each page copied will be at fee of $0.25. If you request it to be faxed, an additional charge of $0.10 per page applies.
- I understand that Victory Physicians and Frank Arian, M.D., Inc. will verify my insurance eligibility, deductible amounts, and coinsurance amounts prior to any surgery or procedure that I may have. I further understand that the fee I am quoted is an estimate based on: 1) anticipated surgery or procedure to be performed and 2) current information provided to Victory Physicians and Frank Arian, M.D., Inc. by my insurance carrier.
- I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/deductibles) and that I have financial responsibility to pay these amounts. I understand that I will be sent two (2) statements for any balance due after the insurance payment. I further understand that if I have not made payment prior to the second statement being mailed, that the second statement will be marked as “Final Notice” and will be sent to an outside collection service. I also understand that I will be responsible for any collection, interest or legal expenses associated with the collection efforts.
- I understand that Victory Physicians will obtain the necessary prior authorizations prior to rending treatment. In addition, it is also the patient’s responsibility to understand which procedures require pre-authorization by your insurance company. I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid for by my insurance carrier.
- I understand that Victory Physicians may also take a verbal request to use my listed credit card for payment on my account or they may also use the same listed credit on my account should my account become delinquent, or to cover an NSF check.
|