Thank you for choosing Gastroenterology Medical Clinic as your gastrointestinal healthcare provider. Our goals are to provide you with excellent gastroenterology care, minimize your out of pocket expenses, and make paying your balance as easy as possible. Our financial department is dedicated to informing you, to the best of our ability, of your estimated portion of the changes for your care and assisting you with any billing questions you may have.
INSURANCE: For the convenience of the patient, we will file medical claims with insurance plans with which we have an agreement as valid insurance information is provided to us. It is the responsibility of the patient to make accurate and detailed insurance information available to us to enable the processing of his or her insurance claim. The patient is to be considered self-pay until this information is provided to us.
The patient is responsible for notifying our office of any insurance changes prior to scheduled appointments. Insurance policies are an agreement between the patient and his or her insurance company. All account balances are the responsibility of the patient. Payment is due from the patient upon receipt of the first statement from our office.
The patient is expected to know her or her insurance benefits to include deductible and co-payments. Co-payments are to be paid at the time of service. If the patient does not have medical insurance, or if Gastroenterology Medical Clinic providers are not participating with his or her insurance carrier, all charges incurred during treatment are due and payable at the time of service.
ALL CHECKS RETURNED FOR NON-SUFFICIENT FUNDS WILL BE ASSESSED A $25.00 CHARGE.
REFERRALS/AUTHORIZATIONS: It is the responsibility of the patient to obtain a referral from his or her primary care physician prior to the scheduled visit if a referral is required by insurance to obtain services provided by a specialty provider. if a referral is not obtained, the patient accepts full financial responsibility for all services rendered.
CANCELLATIONS/FEES: If the patient is unable to keep a scheduled appointment or procedure, it is his or her responsibility to notify our office at least 24-hours prior to the scheduled appointment, or 48-hours prior to the scheduled procedure. Appointments canceled after this time frame may be subject to a cancellation fee of $50.00. Additional fees may also be applied to requests for medical records and for physicians completing paperwork for patients (i.e Disability, FMLA forms). These fees are not covered by insurance, and the patient accepts full financial responsibility for all additional fees.
RELEASE OF INFORMATION: I hereby authorize Gastroenterology Medical Clinic to release information to my insurance company with regard to all treatment as is necessary to obtain payment for their services and to review activity related to the provider's participation as is necessary to obtain payment for their services and to review activity related to the provider's participation with my insurance plan. I assign all benefits, to which the patient or insured is entitled for my treatment and medical services provided to me, to be paid directly to Gastroenterology Medical Clinic. I accept financial responsibility for any and all charges incurred by me that are denied or not covered by my medical insurance. I acknowledge I am bound to pay to services rendered, including all costs of collection and reasonable legal fees should collection to become necessary. I have read and understand this Financial Policy, and by signing, I am in agreement and accept all terms and conditions described above.