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Financial Policies

 

Proof of Insurance‎:‎ ‎ All patients must complete our patient information forms before seeing ‎the‎ ‎doctor‎. ‎We must obtain a copy of your driver license and current valid insurance card‎. ‎If ‎you fail‎ ‎to provide us with the correct insurance information in a timely manner, or do not ‎have an up to‎ ‎date insurance card, payment in full for each visit is required until we can verify ‎your coverage‎.‎ ‎Knowing your insurance benefits is your responsibility‎. ‎Please contact your ‎insurance company‎ ‎with any questions regarding your coverage‎.‎

Deductibles:‎ ‎Deductibles are due at time of service. Most PPO insurances have deductibles that patients are responsible for paying before the insurance will cover services. For your billing convenience, we have made it a policy to collect a portion of your allowable fees that would be applied to your deductible, prior to checking out on the day of service.
The deductible deposits are usually lower than the allowable amount and any remaining amount due should be small and will be billed to you after the insurance explanation of benefits (EOB) has been sent.

Claim Submission‎: ‎ We will submit your claims and assist you in any way we reasonably can ‎to‎ ‎help get your claims paid‎. ‎Your insurance company may need you to supply certain ‎information‎ ‎directly‎. ‎It is your responsibility to comply with their request‎. ‎The balance of your ‎claim is your‎ ‎responsibility whether or not your insurance company pays your claim‎. ‎Your ‎insurance benefit is‎ ‎a contract between you and your insurance company; ‎we are not party ‎to that contract‎.‎

Not Contracted‎:‎ ‎If you have a primary insurance that we are NOT contracted with, the total ‎cost of the visit is your responsibility and due at the time of service‎. ‎If you have a secondary‎ ‎insurance, we will submit ONE claim‎. ‎If payment is made by either insurance company, you ‎will‎ ‎get the reimbursement from our office in the form of a check‎. ‎We do not accept ‎secondary‎ ‎assignment of benefits‎.‎

Contracted‎: ‎If you have a primary insurance that we are contracted with, you are ‎responsible for any co-pay, co‎-‎insurance or deductible at the time of service‎. ‎This ‎arrangement is part of ‎YOUR‎ contract with ‎YOUR‎ insurance company‎. ‎Failure on our part to ‎collect co-pays and deductibles from patients is considered fraud‎. ‎Please help us in upholding ‎the law by paying your co-pays‎. ‎If there is a balance remaining after the primary insurance has ‎paid, we will submit ONE claim to your secondary insurance‎. ‎You are responsible for payment ‎of any office visits or procedures for which your company denies payment‎. ‎We do not submit ‎to the secondary insurance company for reimbursement of your co-pay‎.‎ We do not accept ‎secondary assignment of benefits‎. ‎You are responsible for the patient’s portion that is stated ‎on the primary explanation of benefits‎.

Tertiary Insurance‎: We do NOT accept or bill third party insurance policies‎.

Responsible Party‎: We realize that many families are in a state of change‎. ‎Divorced, ‎separated,‎ ‎single parents and blended families are now common‎. ‎In many of those families, ‎the question of‎ ‎who is financially responsible for the child’s care can be complicated‎. ‎The ‎policy in this office is‎ ‎that the parent‎/‎guardian, who is present with the minor requesting ‎treatment, is responsible for‎ ‎payment at the time of service‎.‎

Statements‎:‎‎ Any unanticipated co-pays or deductibles must be paid upon receipt of the first ‎statement‎.‎ Any balance outstanding for more than ‎90 ‎days after the balance has been ‎transferred to you will be sent to collections‎. ‎Fees associated with the collection process will ‎be added to your balance‎. ‎Partial payments will not be accepted unless otherwise negotiated‎. ‎If a balance remains un-paid; you and your immediate family members may also be discharged ‎from the practice‎.

Forms of Payment‎:‎‎ For your convenience, we accept cash, MasterCard, Visa, American‎ ‎Express, Discover and Debit Cards ONLY‎. ‎No checks accepted‎. ‎In the event that a check is ‎accepted and returned to us from the bank for any reason whatsoever, a $‎45‎.‎00 ‎return fee ‎will be added to your statement‎.‎

Credit Card Authorization‎:‎ You hereby authorize Don Mehrabi MD APMC to obtain and store ‎your credit card information for payment of patient statement balances‎. ‎Your credit card will ‎be charged for the remainder of the patient balance after we have received your insurance ‎payment‎. ‎You have a right to request that we call you before we process this charge‎. ‎A ‎receipt will be included with your statement and the statement will be marked as PAID IN ‎FULL.

Late Fees and Interest Charges‎:‎ Should an outstanding patient statement balance not be paid ‎in full after ‎60 ‎days, a $‎25‎.‎00 ‎late fee will be assessed to your account PLUS a ‎6‎.‎5‎%‎ finance ‎charge on the balance‎. ‎A second $‎25‎.‎00 ‎late charge and ‎6‎.‎5‎% ‎finance charge will be ‎assessed to your account balance in at ‎90 ‎days PAST DUE, and this amount will be sent to ‎collections‎.

Cosmetic Services‎:‎ ‎Services that your insurance company determines are not medically‎ ‎necessary will require full payment at the time of service‎. ‎Examples of such services are ‎Botox‎ ‎treatment, microdermabrasion, chemical peels, sclerotherapy and removal of skin ‎tags, normal‎ ‎moles, or benign keratosis‎.

Missed Appointments‎:‎‎ Please call and cancel at least ‎2 ‎business days before your ‎appointment‎ ‎to help us accommodate other patients‎. ‎Missed appointments can lead to a ‎$‎20‎.‎00 ‎service charge and discharge from the practice‎.

Medical Record Release‎:‎ A service fee may be assessed for copying medical records‎. ‎A ‎release‎ ‎of information form must be signed‎.

Referrals‎:‎ It is your responsibility to obtain a referral, if one is required, from your primary ‎care‎ ‎physician‎. ‎Please check with your insurance company to find out if a referral is ‎necessary‎.

Coverage Change‎: If your insurance changes, please present your new card before your‎ ‎appointment so we can make the appropriate changes to help you receive your maximum‎ ‎benefits‎.

Thank you for thoroughly reading and understanding our Financial Policy‎. ‎Your ‎signature‎ ‎below indicates that you have read, understand and agree to this financial ‎policy‎.‎