Roscoe Village Family Practice
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Monthly Non-covered Benefits Fee In order to continue to provide the best service we can, this office has instituted some features to improve accessibility and communication:
However, this high level of service, convenience and accessibility is not covered or reimbursed by the insurance companies. Therefore, we have decided to charge an Monthly Non-covered Benefits Fee for all patients to pay for the availability of these services. The fee does not apply to your visits, which will be billed separately. This Monthly Non-covered Benefits Fee will not be reimbursed by your health plan, The Monthly Non-covered Benefits Fee $30/month for an individual or $50/month for a family Your credit card will be billed monthly for this amount. If this presents a financial hardship we do have a limited number discounts available based on financial need. _______________________________________ 1. I certify that I have read the above conditions of payment and agree to their terms. 2. I understand that the Monthly Non-covered Benefits Fee pays for the availability of services that are not covered by my health insurance plan. 3. I understand that this Monthly Non-covered Benefits Fee may be changed at any time with at least 3 months of advanced notice. 4. I agree to have my credit card charged on a monthly basis: 5. $30 (individual) $50 (family) ______________________________________________________ Print Patient’s first and last name Date ______________________________________________________ Signature of Financially Responsible Party Office Financial Policy Roscoe Village Family Medicine is here to help you in all aspects of your medical care, including financial arrangements. You are personally responsible for the payment of all medical services furnished to you or your dependents. This includes, but is not limited to, all tests, as well as all procedures performed for you in this office (Emergency and Non-Emergency). If you have medical insurance, this office will submit your insurance forms for payment from your insurance company and will credit such collections to your account. Any insurance co-payments are due and payable at the time of service. If you do not have medical insurance, payment in full is expected to be made at the time services are rendered, unless special arrangements are made in advance. This office will bill you for the remaining portion of your balance, if any, once all insurance claims and payments have been received. If you fail to pay your balance within 30 days after the statement was sent, we may assess a service charge of 1.5% of the remaining balance. If you do not make payments after 3 months of billing, your account may be sent to Collections. You agree to pay all collection costs incurred, in an amount not to exceed fifty percent (50%) of the unpaid balance, should any unpaid balance be referred to a collection agency. In addition should any unpaid balance be referred to an attorney for litigation, all reasonable attorney fees and court costs shall be paid for by you as allowed by the court. A $30.00 service charge will be assessed on all Returned Checks. This office tries its best to estimate what services your insurance company will cover, but we cannot guarantee that your insurance will pay for all services. It is your responsibility to know what services and benefits your medical insurance will cover. If it is determined that you are not eligible for coverage, you will be responsible for payment of all services provided. ____________________________________________________________ Date ______________________________ Print Patient Name _____________________________________________________________ Signature _____________________________________________________________ Relationship_____________________ Responsible Party |
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