Below, is an example of our Financial Budget Plan available to assist you with your medical bills.

 

 Financial Budget Plan

 

 

Patient Name__________________________________             Account   _______________

 

Current Balance Due………………………………………………..$ _______________

 

Down Payment Due…………………………………………………$ _______________

 

Total Financed …………………………………………………….. $ _______________

 

Monthly Payment Due………………………………………...…… $ _______________

 

First Payment Due…………………………………………………… _______________

 

Financial Terms
BALANCES	DOWN PAYMENT	ADDITIONAL MONTHS	TOTAL MONTHS
LESS THAN $500	50%	4MONTHS	5 MONTHS
$501- $1000	25%	5 MONTHS	6MONTHS
$1001 – $2500	10%	7 MONTHS	8 MONTHS
$2501 - $5000	10%	9 MONTHS	10 MONTHS

 

All prices quoted are subject to change according to the exact procedure performed. Any future services provided by any of our physicians will result in additional charges assessed to this account. Should this apply to your account we will reassess your monthly payment and potentially increase the payment amount due. You will be notified by letter of the current charge(s), the new balance due along with your adjusted monthly payment.

 

All payments must be received by the date agreed upon. If there is a missed payment, a notice will be sent to you alerting the possibility of your account becoming delinquent. You will have 14 days to rectify the account to avoid delinquency. If no response is received your account will be turned over to our collection process.

 

Patients with a valid CICP card are given a 50% deduction on their bill. This discount is applied upon receipt of payment. Patients covered by CICP with delinquent accounts will be sent to collections for the full account balance due.

 

Truth in Lending: I understand that there are no finance charges, interest, or other carrying charges.

 

 

 

 

Financial Agreement

 

Thank-you for choosing Surgical Specialists for your surgical care. Please read the following financial agreement to better understand the financial policies of this practice.

 

1. We participate with most major insurance plans. If you have a question about our           participation with your plan, please contact your insurance company for verification.

 

2. Some insurance plans require a referral from your primary care physician to see a specialist. Please bring a copy of the referral with you to your appointment. If you are unsure whether your plan requires a referral please contact your insurance company. Also understand that you will be responsible for all charges related to your visit if a referral is not obtained prior to service.

 

3. We require all co-payments at the time service is rendered. If you are uninsured we require payment in full at the time of service. We accept cash, check, Visa and MasterCard.

 

4. Please understand that you are financially responsible for all charges incurred. However we will bill your insurance company as a courtesy to you but that it is not a guarantee of payment. If a claim is not paid within 60 days of billing you may be responsible for the full balance due. Under certain circumstances, your insurance company may request additional information from you to help with the processing of claims. We request that you furnish, complete and return any information that is needed in a timely fashion.

 

5. Our standard financial policy is as follows:

 

     Insured-for all elective and non-emergent surgeries we require deductible and

                      coinsurance to be paid upon receipt of the first statement.

 

     Non-Insured-for elective and non-emergent surgery we require a 50%

                                payment prior to rendering service with the balance due payable

                                in four monthly installments.

 

      Emergency-we understand that due to extenuating circumstances emergencies

                               arise that may require a review of your account. Please contact a

                               member of our billing office for payment plan options.

 

I certify that I have read and understand this agreement and that I may request a copy of the financial polices of Surgical Specialists.

 

________________________________________________________________________

SIGNATURE                                                                           DATE

 

PRINT NAME

 

 

 

 

Financial Policy for Surgical Specialists

 

• Patients are ultimately responsible for payment of all their medical expenses regardless

  of their insurance status. The amount due must be paid according to the financial

  agreement set forth by the practice.

 

• While the patient is ultimately financially responsible, the practice will bill the

  insurance company as a courtesy to the patient.

 

• In the event that a patient has failed to obtain a referral from his PCP, he will have

  the option of signing a waiver and will then be considered a non-insured patient with

  payment in full due at the time of service.

 

• If the insurance company requests information from the patient to help with the

  processing of a claim, the patient will be expected to provide that information in a

  timely manner. If the patient hasn’t followed up with the insurance company within

  30 days of the requested date the balance due will be transferred to the patient for

  payment.

 

• If insurance information is not provided to our office within 30 days of the date of

  service, we have the option to choose not to file the claim to the insurance on the

  patient’s behalf (based on the timely filing guidelines of the insurance company).

 

• Payment issues or the need for financial counseling to meet patient financial

  responsibilities must be brought to the attention of the billing staff before service

  is rendered.

 

• Every effort will be made to ensure we have the patient’s correct information, a review

  of the patient’s demographics is to be done monthly by the receptionists. A new patient

  registration form is to be filled out and signed by the patient yearly and copy of their

  insurance card obtained.

 

• Payment plans will be made available to help patients meet their financial obligations.

  When determining payment arrangements, we will follow the collection protocol set

  forth by the practice.

 

• We do not collect interest on outstanding accounts or charge late payment fees.

 

• If a patient defaults on payment terms, we are no longer obligated to continue under our

  original agreement. At that time we may choose to place the account with an outside

  collection agency.

 

• Delinquent accounts that are 90 days past due are reviewed for collections. This will

  include one follow up phone call from our collection coordinator at which time payment

  in full will be expected within 10 days or the account will be placed with an outside

  collection agency. The agency currently used by this practice is:

             CollectionCenter  PO Box 4000  Rawlins, WY 82301  (800)442-2574

 

Effective 1/1/2006

Payment Policy