Family Practice Specialists of Richmond, P.C. Financial Policy
Thank you for choosing us as your primary care physician. We are committed to providing you with quality and affordable health
care. In order to answer some of the questions from our patients regarding patient and insurance responsibility for services
rendered, we have developed and are providing the following payment policy. Please read it, ask any questions you may have,
and sign at the bottom. A copy will be provided to you upon your request.
Patient Name: ________________________________________
1.
Consent to Treat. I consent to medical treatment by the physicians and staff of Family Practice Specialists of
Richmond, PC and authorize the release of medical information to other physicians involved in my care or to my
insurance company. I grant consent for FPSR to treat the minor child ,____________________________________.
2.
Insurance. We participate with most insurance plans, including Medicare. Knowing your insurance benefits is your
responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If
your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. It is your
responsibility to contact your insurance company to expedite their payment. Please be aware that some, and perhaps
all, of the services you receive may or may not be covered or not be considered reasonable and customary by your
plan. You must pay for these services in full at the time of your visit. We must obtain a copy of your current valid
insurance card and driver’s license. If you do not have an up-to-date insurance card, payment in full for each
visit is required until you can provide coverage verification.
3.
Co-payments and Deductibles. All co-payments and deductibles must be paid at the time of service. This
requirement is part of your contract with your insurance company. Failure on our part to collect these monies from our
patients is considered fraud and violates our participation with your plan. If we do not participate with your
insurance plan, or you do not have insurance coverage, payment in full is expected at the time of service.
We accept cash, check, money order, VISA, MasterCard, and Discover. If your financial institution, for any reason,
returns your check, you will be charged a return check fee. All returned check and check fees must be paid before
your next office visit.
4.
Medicare Authorization. I request that payment of authorized Medicare benefits be made either to me or on my
behalf to Family Practice Specialists of Richmond, PC for any services furnished me by a practitioner associated with
that group. I authorize any holder of medical information about me to release to the Health Care Financing
Administration and its agents any information regarding my Medicare claims under Title XVII of the Social Security
Act.
5.
Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 30 days to pay
your account balance. Partial payment will not be accepted unless otherwise negotiated. Please be aware that if a
balance remains unpaid, we may refer your account to a collection agency, and you and your family members may be
discharged from this practice. You will also incur additional expenses up to 33 1/3 % of your balance to cover
collection fees. If this occurs, you will be notified by certified mail that you have 30 days to find alternative medical
care.
6.
Missed Appointments. It is your responsibility to contact our office within a reasonable amount of time if you are
unable to keep an appointment. If you fail to do so repetitively, you may be discharged from the practice.
7.
Miscellaneous Fees.
After hours Calls—In the event you have a medical emergency after our office is closed, we provide on-call service to our
patients 7 days a week, 24 hours per day. There may be a fee of $25 for non-emergent calls. We do not give
medications or refills after hours.
Completion of Forms—From time to time you may need medical forms completed. There is a fee assessed for this service
relative to the chart review and time necessary for this completion. Reasonable fees are charged on a case-by-case
basis.
8.
Laboratory Policy Effective 6/1/2010. In an effort to better manage your healthcare needs, the following laboratory
policies have been established. Labwork will be drawn in conjunction with office visits only, with the exception of
patients requiring Protimes, who may continue to walk-in for those tests. Patients needing fasting lipids who come
later in the day will be directed to make an early morning lab appointment.
9.
Medication Refill Policy Effective 6/1/2010. Only by physical exam can we manage your medication necessity,
therefore, once a patient has exhausted all refills on a particular medication, the patient will be required to come in for
an appointment in order to obtain another prescription. If your insurance company requests a medication change, we
will need to see you to determine the most appropriate choice in medication.
I hereby give lifetime authorization for payment of insurance benefits to be made directly to Family Practice Specialists of
Richmond for services rendered. I understand that I am financially responsible for all charges whether or not they are
covered by insurance. In the event of default I agree to pay all costs of collections, and reasonable attorney’s fees. I
hereby authorize Family Practice Specialists of Richmond to release al information necessary to secure payment of
benefits. I further agree that a photocopy of this agreement shall be as valid as the original.
I have read and understand the payment policy and agree to abide by its guidelines.
______________________________________________________________________________
Signature of patient or responsible party
Date
Our practice is committed to providing the best treatment to our patients. Our prices are representative
of the usual and customary charges for our area. We hope that you will find these written policies
helpful. Please let us know if you have any questions.