INSURANCE – You must provide your insurance card at the time of service, and we ask that you inform us of any changes to your address, phone number, employment status, or insurance coverage. If you do not have the information requested, i.e. insurance cards, we may ask you to reschedule your appointment or pay in full at the time of service. We will only accept Medicaid as secondary insurance to a commercial insurance that we participate with, or Medicare. We do NOT accept Medicaid as a primary insurance and will NOT retroactively bill any service to Medicaid once presented as secondary. We will only accept Michigan Medicaid as a secondary insurance from the date it is presented forward. If circumstances arise that you are only covered by Medicaid; you have the option to waive the Medicaid benefits at our office, or you will be expected to transfer your care to a Provider that accepts Medicaid payment.
CO-PAYS, DEDUCTIBLES, & NON-COVERED SERVICES – All co-payments, deductibles and non-covered services are due at the time of service. We cannot waive co-pays or deductibles as this would be a breach of contract between you and your insurance carrier.
CLAIM SUBMISSION – We will submit to all insurance companies as a courtesy. If we do not participate with your insurance carrier, you will be expected to pay in full at the time of service as your insurance will reimburse you directly if you have the appropriate benefits for the services performed.
NON-PAYMENT – If your account becomes 90 days past due, you will receive a pre-collection letter. Your medical care is our priority and your compliance with financial responsibilities is appreciated. If however, your account remains unpaid and we forward your account to an outside collection agency, the account will be assessed a 40% collection fee of the remaining balance.
RETURNED CHECK – In the event that we receive a returned check due to insufficient funds, or a stop payment; a $30 fee will be assessed to your account.
INSURANCE FORMS, MEDICAL RECORDS & DISABILITY FORMS – We charge an administrative fee for completing insurance forms, copying medical records and disability verification forms. We request 7-10 business days to complete.
FORMS OF PAYMENT – We accept CASH, CHECK, MONEY ORDER, MASTERCARD, VISA, DISCOVER & AMERICAN EXPRESS.
CANCELLATION/NO SHOW POLICY – We ask if you need to cancel or reschedule an appointment, that you do so 24 hours prior to your scheduled time. Our “No Show” policy allows you to miss one appointment. If you should miss a second appointment, a $25.00 charge will be added to your account that must be paid in full before future appointments.
I understand and agree that by signing my Patient Information Form I will be financially responsible for services provided to me and all costs of collection incurred by the practice should my account be determined delinquent. I have provided the practice with all of my insurance coverage and will keep this office informed if my coverage changes. I have read and understand the policies and how they affect me and my financial obligations to the practice. My signature also indicates that I authorize the release of any medical information necessary to process my insurance claims. I understand and agree that I am responsible for all charges not authorized by my insurance carrier.