9/21/10 – Printable Financial Policy form
PLEASE READ CAREFULLY
To complete this form, please go to printable Financial Policy form. Print the form, sign and date, then return to office. You can either return the form in person, mail it, fax it, or scan the signed form and email it to firstname.lastname@example.org . This form will become part of the Patient’s records.
FINANCIAL POLICY FOR PATIENT CARE SERVICES
John A. Schmidt, Jr., M.D. LLC
To help Dr. Schmidt provide his patients with cost-effective health care, it is necessary to have a Financial Policy stating the payment requirements for services rendered. Patients are responsible for payment of all services provided by the practice. In general, it is the policy of the practice to submit electronic claims to primary and secondary insurance carriers and Medicare as a courtesy provided we have accurate and complete insurance information. If we have not received payment from the insurance company within 30 days of claim submission, the patient is responsible for the unpaid balance.
If you have insurance and Dr. Schmidt has been accepted by your carrier as a credentialed physician, we request that you pay during the visit any fees for which you, according to your plan, are directly responsible including deductibles, co-pays, co-insured amounts, and non-covered services. Insurance plans which have credentialed Dr. Schmidt, as well as plans to which Dr. Schmidt has applied for credentials, currently include Horizon Blue Cross/Blue Shield, United Health Care, Oxford, Qualcare, Aetna, and Medicare (please see next paragraph). We accept personal checks and all major credit cards. As a convenience, we will give you the opportunity to preauthorize credit card charges for unpaid balances during your visit.
Dr. Schmidt is happy to apply to your insurance carrier for credentials and is willing to delay receipt of payment during the often lengthy credentialing period.
If you do not have insurance, prefer to be “self-insured”, or Dr. Schmidt has not been accepted by your insurance carrier as a credentialed physician despite his best efforts, and you are not covered by Medicare, you will be considered a “self pay out-of-network” patient. Payment is due in full at the time of the office visit. Some patients prefer this approach rather than deal with the complexities of health insurance.
No-shows and cancellations less than twenty four hours in advance of an appointment result in financial hardship for the practice. Failure to give notice 24 hours prior to your appointment will result in a $25 fee to be paid by the patient. Likewise, returned personal checks will result in a $25 charge.
Financial hardship should not stand in the way of medical care. Please discuss hardship with the office staff as soon as possible.
Please discuss any questions you might have directly with the office staff. Thank you.
2006 Highway 71, Ste. 3
Spring Lake Heights, NJ 07762
Email to: email@example.com
To complete this form, please go to printable Financial Policy form. Print the form, sign and date, then return to office. You can either return the form in person, mail it, or scan the signed form and email it to firstname.lastname@example.org . This form will become part of the Patient’s records.