It is our hope that our patients understand our credit, collections, and office policies are a necessary part of assuring the financial resources required to maintain vital health care services for our patients and the community. Our goal is to provide and maintain a good provider-patient relationship. Letting you know in advance of our office and financial policies allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully and initial. If you have any questions, do not hesitate to ask a member of our staff.
As a result of the changes in healthcare, many families have chosen individual high deductible health plans to help lower their monthly insurance premiums. With your credit card on File, we securely save your credit or debit card and work with your health plan to determine your payment amount after each visit. We process the payment for you automatically and email you the receipt. The Credit Card on File eliminates the hassle of writing a paper check and mailing in a payment. We do all the work for you! Plus, you will not receive a paper invoice in the mail. This eliminates the chance your personal
information can be viewed or stolen by others.
Appointments: We value the time we have set aside to see and treat your needs. If you are not able t o
keep an appointment, we would appreciate no less than 24-hour cancellation notice. Please remember that all our appointments are scheduled appointments and if notice is not received no-show and late
cancellation fees will apply and are as follows: $30.00.
If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, on certain days it may be necessary t o reschedule your appointment.
Insurance Plans: It is your responsibility to keep us updated with your correct insurance information.
Upon arrival we ask that you come prepared t o present your insurance card at every visit t o verify that
our office has the most updated card on file
It is your responsibility t o understand your benefit plan. If our services are not covered, you will be responsible for payment
Referrals: Advance notice is needed for all non-emergent referrals, typically 3 business days. It is your
responsibility to know if a selected specialist or lab participates with your insurance.
Co-pays are due at the time of service.
Self-pay patients are expected t o pay for services in full at the time o f visit. This includes patients that
w e do not participate in their insurance plan. Our office will be happy to furnish a printout with all the
necessary codes for you to file the claim for reimbursement with your insurance company for which we
do not participate
Patient balances are billed monthly and we ask that you pay your statement balance in a timely manner.
If previous arrangements have not been made with our billing office, any account balances over 60 days
old will be forwarded to a collection agency.
For scheduled routine follow ups, any outstanding balances must be paid prior to the visit or you will be
asked t o reschedule.
We accept cash, check, and all major credit cards. A $30.00 fee will be charged for any checks returned for insufficient funds or any other reason the check would be declined, Checks will no longer be permitted as a method of payment. Heart Center PLLC reserves the right to change fees without notice.
I have read and understand this Financial and Office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined in this document.