Please review the following financial policy. We ask that you initial each policy after you have read it. On the other
side of this policy sheet our Credit Card on File Policy and your authorization are listed. Please return this form to the
check-in desk. If you have any questions, feel free to direct them to any member of our staff.
According to the contract you entered into with your insurance plan, you are responsible for any and all copayments, deductibles and coinsurances at the time of your visit. Self-pay patients and those with high
deductible plans are expected to pay for services in full at the time of the visit. If we do not participate in
your insurance plan, payment in full is expected at the time of your visit. We will supply you with an invoice
that you can then submit to your insurance company for reimbursement. There is also an additional charge
billed to your insurance for any appointments after 5 p.m. , weekends and holidays.
Copayments are always due at the time of service, as per your insurance policy requirement. We are not
allowed to see your child if you do not pay your co-pay. A $25.00 service fee will be charged, in addition to
your copayment, if the copayment is not paid by the end of that business day.
The adult accompanying the patient to our office is responsible for payment of the applicable co-pay,
deductible or coinsurance regardless of whether it is the parent or guardian. For instance if another family
member brings your child to the office,he or she should have with them a copy of your insurance card and
am applicable payment. In divorce or separation situations we do not split the financial responsibility nor do
we bill 2 separate individuals. The adult accompanying the patient to our office is responsible for payment of
the service.
Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits (EOB).
Your remittance is then due within 10 business days of your receipt of your bill. For any unpaid balances
over 30 days, a $25 bill fee will be added to your account and will continue for each month the balance
remains unpaid. If after 90 days if you have not satisfied payment, or made other arrangements, your
account will be sent to a collection agency and you will be responsible for any legal costs involved in
collecting your past due account, plus an additional 40% of the balance.
In order to avoid any unnecessary charges and to expedite your check in and checkout process, we require
you to keep a credit card on file with us. Your credit card information is stored by our merchant services
vendor whose name is Pay Junction. This will be kept securely, fire walled and protected and only will
show the last 4 digits of your account number. This allows us to charge your card for any co-payment and
balance payments that are due at the time of your visit. If you do not have a credit card on file, or do not
pay your balance due at the time of your visit, then a monthly billing fee of $25.00 will apply for each month
the balance is unpaid.
For your convenience we accept cash, checks, debit cards and credit cards (Visa, MasterCard, and
Discover.). A $40.00 fee will be charged for any check returned for insufficient funds and from that point
forward we will accept only cash transactions.
Unless other arrangements have been made with our billing department, delinquent accounts must be paid
in full before we can offer you an appointment.
It is the policy of this office to keep a credit card on file. As most insurance plans require deductibles
and copayments not known to you at the time of your visit, we require a credit card on file to pay this
balance upon adjudication of claims. Otherwise you will need to keep a credit of $200.00 on your
account or pay for services rendered at check- out the day of your appointment. We feel this best
addresses any financial responsibility you have and we do not want to burden you at the time of your
visit. Please provide us with your email so that we can notify you when we do charge your credit card
on file
If you do not wish to leave a credit card on file, then you will be billed the day of service and payment
will be expected at that time. Once we have billed your insurance company, we will credit your account,
and mail you a check, for any part of the cost of the visit that was paid by your insurance company.
Please provide us with your email so we can advise you when we receive notice from your insurance.
Why do we require a credit card on file?
Many patients told us they would like an easier way to address the finances of their medical visits. This
was designed to eliminate the trouble of waiting for statements, mailing checks or calling with credit
card payments.
How does this process work?
Every day we run insurance eligibility; some insurance companies give us details of your plan. These
reports tell us if you have a co-payment, coinsurance or deductible. For the accounts with a coinsurance
or deductible we require a credit card be kept on file. We will send the claim to the insurance company
and it will tell us how much you owe. We then charge your credit card. If you provide us with your email
address, we will then notify you that we have used your card.
Where will my credit card information be stored?
This information is stored by a merchant services vendor called Pay Junction, on a secure, fire walled
program that only shows the last 4 digits of your account.
How often will you run my credit card?
We will run your credit card as soon as we hear back from your insurance company which usually takes
approximately 2 weeks
I understand this form is valid until the expiration date of the listed credit card, unless I cancel the authorization
by written request.
Patient Name:_____________________________________________
Guarantor Name:____________________________________________
Guarantor Signature: _________________________________________
Dated: ___ __/______/_______
Credit card policy 1/1/2013