Wellness Medical Practice welcomes you as a patient. The practice strives to provide its patients with excellent healthcare. In order to keep the cost of our medical services comparable with other medical providers in the area, Wellness Medical asks patients to become familiar with the practice’s Financial Policy. PAYMENT: Each office visit payment is rendered at that time, unless prior payment has not been arranged with billing staff. Payments are listed as co-insurance and co-pays for their insurance holders. Wellness Practice accepts all monetary payments debit and credit cards. A $25.00 return check fee will be applied to account. An outstanding bill that is over 60 days will be required to make payment arrangements before they can be seen in this office for services. The Wellness Medical Practice realizes that families have unforeseen hardships.
The practice will recommend other low cost facilities for non-covered services. MINORS: The parent is responsible for payment and will receive billing statements. The parent will have to sign consent for treatment and procedures required for unaccompanied minors. INSURANCE: The Wellness Medical Practice will submit claims for payment. The patient is responsible all other charges. Wellness Medical Practice will not file secondary claims. PREPAYMENTS: Wellness Medical Practice accepts prepayment for services in the form of personal check, bank debit/credit cards, or cash. A receipt will be given to responsible party the receipt will verify services rendered. MANAGED CARE: HMO plans require a referral in order to be seen by a specialist. You will not receive a referral after services are rendered.
WORKERS’ COMPENSATION AND AUTOMOBILE ACCIDENTS: Injury or automobile accident, you must obtain all information related to the insurance provider before patients visit. REFUNDS: Patient should submit in writing a refund of any monies he believe is owe and allow up to 30 for a response. RETURNED CHECKS: A charge of $25.00 for returned checks, to be paid in the form of a money order or cash. The patient may be placed on cash only visits. LATE AND INCOMPLETE PAYMENT: Wellness Medical Practice will setup an installment to pay for six months. If patient continue to be late, the agreement may be voided. Wellness Medical Practice will full payment for each office visit. MEDICAL RECORDS COPIES: Charges for copies of medical records upon request of patient:
* $10.00 — under 20 pages
* $15.00 — 21-49 pages
* $20.00 — over 50 pages
Other insurance providers and professionals will have a $15.00 fee:
* .25 — under 100 pages
* .10 — over 100 pages.
MISSED APPOINTMENTS/LATE CANCELLATIONS: Missed appointments could keep another patient from being seen by their physician. Therefore, if Wellness Medical Practice does not receive a cancellation of 24 hour before your appointment time the patient will be charged a no show fee of $50.00. If you don’t understand any part of this financial policy, please contact us at (XXX) XXX-XXXX anyone in our billing department can answer your question. I understand the document set forth to me by Wellness Medical Practice Policy.
Under this policy all benefits will be paid directly to Wellness Medical. Wellness Medical has my permission to release my medical information to process a claim. In the event my account becomes delinquent this office will turn the account over to collections. I am aware I will continue to be responsible for all charges accrued through the collections agency. I agree to the Wellness Medical Practice’s Financial Policy.