We are committed to providing you with the best care possible. This goal is best achieved if everyone is aware of the financial policy, which is an agreement between the doctors of the practice and the patient. Your clear understanding of the financial policy agreement is important to our professional relationship.
Payment for services is due at the time services are rendered, except as outlined as follows. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. It is the responsibility of the patient to provide accurate and timely insurance information. Inaccurate or untimely information given to the staff that results in denial or non-coverage by your insurance company will result in the patient being responsible for payment.
Physicals, sick visits, and follow up appointments may be rescheduled if there are outstanding balances or if a co-payment is not made at time of service. If you are experiencing financial difficulty, please let us know. Health insurance is a contract between you, your employer, and your insurance company. It is important for you to be an informed consumer who understands the specifications of your insurance policy (eg, vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiographs, laboratory tests, and emergency hospital care) given made with the billing department. A $10 billing fee will be charged to you if your co-payment is not made at the time of service. Balances not paid in full within 10 days of the date on the final request letter will be forwarded to a collection agency. If your account is forwarded to a collection agency, we will continue to see you on an emergency basis only for the next 30 days, giving you time to find a new source of medical care.
A $35 fee will be charged for all returned checks and your account will be placed on a “cash-only basis.” We will accept payments only by cash or credit card until the balance is cleared.
We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact our billing department promptly for payment arrangements and assistance in the management of your account.
The Financial Agreement
We must emphasize that as your healthcare providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from THE DATE SERVICES ARE RENDERED. Therefore, it is necessary for you to know what benefits your insurance plan provides for you.
I HAVE READ AND FULLY UNDERSTAND THE FINANCIAL POLICY SET FORTH BY HARRIS INTERNAL MEDICINE. I AGREE THAT IF IT BECOMES NECESSARY TO FORWARD MY ACCOUNT TO A COLLECTION AGENCY, I WILL ALSO BE RESPONSIBLE FOR THE FEE CHARGED BY THE AGENCY FOR THE COSTS OF COLLECTION IN ADDITION TO THE ORIGINAL AMOUNT DUE. I UNDERSTAND AND AGREE THAT THE TERMS OF THIS FINANCIAL POLICY MAY BE AMENDED BY THE PRACTICE AT ANY TIME WITHOUT PRIOR NOTIFICATION TO THE GUARANTOR.