417 Health Care Financial Policies Welcome to our office. Thank you for choosing 417 Health Care for your medical needs. We are committed to providing you with the best possible care. We accept cash, checks, and major credit cards. In order to better serve you, we ask that
you please take a few minutes to read the following policies specific to our practice and your insurance.
Insurances - If you have insurance, we will do all we can to help you receive maximum benefits. The percentage of coverage by your insurance company may be based on your insurance company's own reduced fee schedule for medical services and may be less than actual charges, resulting in lower coverage for you. We have no control over this situation. Lower payment is a direct result of the plan selected by yourself or your employer. Please be advised that we cannot waive co-payment. We are
required by law to collect your co-payment. Medicare Patients: This office accepts Medicare assignment. Medicare patients are fully responsible, however for the initial yearly deductible and the 20% co-insurance. This payment is to be made at the time
services are rendered.
Financial Policy - Medical Records, Releases, and Insurance Assignments - l request and authorize Daina Kays FNP-BC or assistant of their choice to perform medical/physical therapy medical treatment. I also authorize the taking of photographs for medical use by this office. I permit a copy of these authorizations and assignments to be used in place of this original
Physician Insurance Assignment - We require insured patients to complete assignment of benefits authorizing insurance to
remit payment to 417 Health Care. I hereby assign all medical benefits, to which I am entitled, by private insurance or any
other health plan to: 417 Health Care. This assignment will remain in effect until revoked by me in writing. I authorize payment directly to 417 Health Care for medical benefits. Any services for which assignments are not accepted are
acknowledged to be my full and complete financial responsibility. I understand that I am financially responsible for all charges not paid by said insurance. Medicare - I certify that the information given by me in applying payment under title XVII/XIX of the Social Security Act is correct.
Responsibility of Account - I agree that if the amount of insurance benefits be insufficient to cover expenses, I will be responsible for the payment of the difference. I will be responsible for the entire amount due to professional services rendered if the expense is not covered by insurance.
Collection Information - I understand that my portion of all fees is due at the time treated unless previous arrangements have
been made. I will be billed for my po1tion of any fees not paid at the time of service. Any balance which are 90 days past due will be eligible to be turned over to a collection agency. Collection Agency fees are recognized to be my (the patients) responsibility. There will be a $35.00 fee for any returned check. We know at times patients do not have any insurance. If this is
the case the procedure and cost will be discussed prior to service. At this time, a payment plan will be set up.
Attendance and Cancelation Policy - It is very important to note that, for you to receive the optimal benefit from your office
visit/therapy, you must be consistent in attending all your scheduled appointments. Additionally, in order to be as efficient in our
schedules as possible we kindly ask for at least 24-hour notice for cancellations. At our discretion, you may be subjected to a
$50.00 cancellation fee. If you do not show for an appointment, a $50.00 no-show fee will be charged. In the event that you are unable to attend your appointments constantly, you have 2 same-day cancels, or 2 no-show appointments, you will be discharged
from care. We are very committed to your rehabilitation and improved quality of life. Therefore, we ask that you allow us to help
solve any issues that may prevent you from attending the prescribed number of treatment sessions as in your plan of care.
Insurance Benefits - Please check your benefits co-pays, co-insurance, deductibles, and any limitations to the number of therapy visits allowed. The back of your insurance card has a "member services" phone number which you may call to inquire about and verify the necessary information. You are providing your insurance information and contractually obligated to your insurance carrier's fees, including co-pays, co-insurance, and deductibles. We are contractually obligated to file your claim with your insurance carrier as well as collect any fees associated with your care. Please notify the front desk of any changes in your insurance coverage.
Patient Payments and Charges - Please be prepared to pay any co-pay/deductible amounts at the time of each appointment.
Please note: We do use other facilities such as hospitals, laboratories, etc. for bloodwork, cultures and biopsies. Therefore, you may be receiving billing information from these facilities. Thank you for understanding our financial policies. We are here to help you. Please let us know if you have any questions or concerns.
Please carefully read and initial each statement (1-6) and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you .
I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed.
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