POLICIES AND FINANCIAL OBLIGATIONS OF PATIENT

Healthy Women’s Care POLICIES AND FINANCIAL OBLIGATIONS OF PATIENT

Thank you for choosing Healthy Women’s Care for your gynecological and primary care needs.

We are pleased to welcome you to our practice. Our chief concern is that you and your family receive the highest quality of care.

We understand that situations arise which lead to financial difficulties and scheduling conflicts.

Please bring these issues to the attention of the Practice Administrator or billing department to allow us to help you manage these issues in the most effective manner. Please be advised that your insurance company has a contract with you and your employer. We will be glad to submit your claims for payment for you; however, the final responsibility for payment due for services rendered is the sole liability of you, the patient or the guarantor.

Our policies and financial obligations of the patient are as follows.

1. We accept cash, Visa, or Mastercard.
2. Medicare usually only covers exams every two years. You will be responsible for any deductibles and/or coinsurance that are not covered by Medicare.
3. Your co-payment and or deductable is due at the time of service.
4. Due to new FTC laws, and for your safety, we will now ask to make a copy of an identification card.
5. We have a twenty minute late policy. Anyone arriving after twenty minutes will need to be rescheduled.
6. As a courtesy to our patients, we require 24 hour notice of cancellation of your appointment. Anything other will be subject to a $30 missed appointment fee. If two appointments are missed without a 24 hour notice we will not be able to continue providing services to you
7. Record releases to other doctors are subject to a $20 administrative fee and legal requests of record are subject to a $50 charge.
8. If an account is placed in collections to our outside agency; additional charges will be placed on your account to offset agency fees.
9. Please verify with your insurance company where you are allowed to go for radiology and laboratory services (ultrasound, mammograms, etc).
10. It is the responsibility of the patient to determine whether a referral is needed for services.
11. This also serves as an assignment of insurance benefits to be paid directly to Healthy Women’s Care.

You also give us permission to release information to other physicians, financial institutions, insurance companies, CMS and its affiliates or attorneys as relevant to the care you receive from Healthy Women’s Care LLc. Your medical records will not be released to any family member, individual or other agency without your, your personal representative, or your guardian’s prior written authorization.