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 and our providers offer our patients 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 insurance carriers provided we have accurate and complete insurance information. For eligibility verification, be sure to show your current insurance card at every office visit.
If we have not received payment from the insurance company within 30 days of claim submission, the patient is responsible for the unpaid balance.
According to your policy, we request payment of your copay during your visit. After we have received payment from insurance carriers, any remaining balance will be applied to your account. These amounts will be reflected on your statement and payment will be due upon receipt.
Currently, our office accepts patients with Medicare and policies from the following major insurance carriers, including but not limited to, Horizon Blue Cross/Blue Shield, Aetna, United Healthcare/AARP, Cigna, and AmeriHealth. If your insurance is not listed, please contact your insurance company or our billing department to verify our providers’ network status.
If Dr Schmidt or our providers are not credentialed by your insurance carrier or you do not have insurance, you will be considered a “self-pay, out-of-network” patient. Payment will be due in full at the time of the office visit.
No shows and cancellations less than twenty-four hours in advance of an appointment result in a financial hardship for the practice. We appreciate that patients will make every effort to give cancellation notice 24 hours prior to an appointment.
Financial hardship should not stand in the way of medical care. Please discuss hardship, including loss of insurance, with our staff as soon as possible.
Please discuss any questions you might have directly with our 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.