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.
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, coinsurance 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 office. 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 may 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 may 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: Missing an appointment affects our providers as well as patients who have been waiting for appointments. Please call and cancel at least 24 hours before your appointment to help us accommodate other patients. Missed appointments can lead to a $45.00 - $150.00 charge and discharge from the practice. Please refer to the Appointment/Cancellation/No Show Policy.
Medical Record Release: A $35.00 service fee may be assessed for copying medical records. A release of information form must be signed.
Referrals and Authorizations: 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. It is YOUR responsibility to understand your insurance policy and have the correct authorization prior to the visit and/or procedure. All charges for visits or procedures done without a valid authorization will be the SOLE RESPONSIBILITY of the patient.
Identity Theft: Our system is secured. In the event that there is a breach of our electronic medical records or financial records, you will be notified and a full investigation will be performed. We value your personal information and will take use the highest and full extent of the law to persecute anyone who is involved in accessing, disseminating, or using stored personal information. Identity theft or personal information breeches will be recognized by either the patient's reporting financial institution or insurance inquiry, or by our routine auditing of our system security. Any breach will be recognized and login information will be analyzed. We will contact the appropriate authorities and report any infraction. In addition, if the breach is electronic, we will shut down our system for a period of time to reinsure its safety and perform diagnostic testing. All persons involved will be prosecuted. Our practice will not be financially liable for breaches of personal information
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.