The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made. We accept cash, check or credit cards.
No post-dated checks will be accepted.
Insurance is a contract between you and your insurance company. In most cases, we are NOT a party of this contract. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the services. Although we may estimate what your insurance company may pay, it is the insurance that makes the final determination of your eligibility and benefits. If we are Out-of-Network with your insurance, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are Out-of-Network for your insurance, and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us promptly.
We participate with most insurances. We do recommend you contact your plan to verify our providers are In-Network.
Certain insurances require that you obtain a referral or prior authorization from you Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility.
Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. Liability cases will also be considered self-pay accounts.
You will receive an accident questionnaire to be completed. As a courtesy, we will submit the claim to the insurance carrier provided on the form. It is your responsibility to seek reimbursement from them. If the questionnaire is not returned or completed and/or we receive a denial on your claim, you will be responsible for payment in full.
It is the patient's responsibility to provide our office staff with employer authorization/contact information regarding a workers' compensation claim. If the claim is denied by the workers' compensation insurance carrier, it then becomes the patient's responsibility. At your request, we will submit the claim to your primary medical insurance carrier with a copy of the workers' compensation insurance denial. If your primary medical insurance carrier's claim is denied, you will be responsible for payment in full.
There is a $35 charge for a returned check payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.
Often, we are asked to provide services not reimbursed by insurance and above and beyond what is a reasonable extension of a service provided for a medical condition. These services might include writing a letter, FMLA form completions, insurance forms, disability forms, or sending a fax at your request. Under those circumstances, a reasonable charge will be requested prior to completing the requested services, which you will be notified of the cost.
It is our office policy that all past due accounts be sent a minimum of 4 statements. If there has been no communication with our office regarding your past due account(s), payment arrangement has not been set up, and/or arrangement kept, and/or if no resolution can be made, the account will be sent to the collection agency or attorney, and possible discharge from the practice. In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs including attorney fees and court costs. Any appointments after an account has been placed in collections will be set to ‘Self-Pay’ until good credit status has been maintained. As a courtesy, we will submit your claim to the insurance provided.
These policies help the office provide quality care to our valued patients.
If you have any questions or need clarification of any of the above policies, please feel free to contact us.
I agree to abide by the policies of the office and understand that if I do not, I may be asked to seek care elsewhere.
Acknowledgement Signature Required on Demographic Form.
East Lincoln Family Health Professionals, PC. RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THE INFORMATION ON THIS SITE AT ANY TIME.