Roscoe Village Family Practice
| Payment Policy | |
|
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 |
|
