Patient Billing Agreement Medical Services Billing–If we are in

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Patient Billing Agreement Medical Services Billing–If we are in Powered By Docstoc
					Mark C. Winslow D.O. Rocky Mountain Osteopathic Medicine
750 East 9th Ave., Suite 205, Denver, CO 80203 Office: 303-831-6274 Fax: 303-648-5709
Patient Billing Agreement Medical Services Billing–If we are in-network for your insurance we will submit the charges directly to your primary insurance if you sign this form. After your insurance(s) complete(s) payment to us you are responsible for payment of any allowable remaining patient balance. Co-pays -are always collected at check-in. If you do not pay them you will not be seen. Deductibles – if your plan has a deductible, you are required to pay a portion of it at check in. After insurance processes the claim, you will be billed for any remaining balance. Self-Pay Patients- If you are “self-pay” for any routine visit you must pay $100 in advance at check-in. At the end of your visit you can: 1. Pay the total charges (less the pre-paid $100) for services and tests done during the visit; OR 2. Sign a Payment Agreement stating you will have the balance paid in full within 4 months or before your next visit, whichever comes first. Billing Process - Once we have received the final payment statement from your insurance, we will mail you a statement requesting the remaining allowable patient amount. You will receive a second bill 30 days later for remaining balances. If you are unable to make payment in full before 60 days, you may call our billing department and make installment payment arrangements to avoid having your account go to the collection agency. If your account is not paid 30 days after we send you the second statement, your account will be turned over to our collection agency without further notice from us. After your account has been turned over to our collection agency, you will be responsible for the outstanding balance you have with us as well as any agency fees, legal/attorney fees, and court costs. This could be placed on your credit record and may affect your ability to make any credit purchases. Other Billing Policies: Cancellations / ‘No-shows’ – You are expected at your scheduled appointment time because that time slot has been reserved for you to see the Doctor. Not showing up for a scheduled appointment interrupts the scheduled patient flow, does not allow the Doctor to see other patients in need, and does not allow RMOM staff to use our time effectively. Accordingly, we handle “no-shows” as follows: If you do not call us to cancel or reschedule at least 24 hours in advance of your scheduled appointment, this will be considered a “no-show”, and you will be charged a $25 fee for each “no- show Auto Accident Patients - If you are being seen for an auto accident, you will be responsible for paying the full balance on the day of your appointment. We will give you a summary of your office visit charges for you to submit to the autoinsurance company. We cannot bill your insurance company for this type of visit. Workers Compensation Visits - If you are being seen under a Workers Compensation claim you must have a completed injury form from your employer for billing and reporting purposes prior to being seen or you will be treated as a “Self-pay” patient. We cannot bill your regular medical insurance for these claims. If you have been referred by another physician to our office this has already been taken care of for you. Routine Physicals and Preventive Services - It is your responsibility to know the benefits covered by your insurance. Please find out in advance if your insurance will pay for the physical or other preventive services. Some will pay for them and some will not. You may be required pay for these services because many insurances do not pay for these services. Company Physicals - If you are coming in for a Company physical, please make sure that your company has approved RMOM as Providers so that we can bill them directly for services. If we have no arrangement with your company, you will be required to pay in full at the time of service, and we will give you a receipt to submit to your company for reimbursement. Payment methods accepted - For your convenience, we accept Visa, MasterCard, American Express, Debit Cards linked to your credit card account, money orders, cash or personal checks with proper ID.


Mark C. Winslow D.O. Rocky Mountain Osteopathic Medicine
750 East 9th Ave., Suite 205, Denver, CO 80203 Office: 303-831-6274 Fax: 303-648-5709
Insufficient funds - If your check is returned due to insufficient funds, you will be charged a $20 fee by us in addition to whatever your bank charges you. You will receive a statement for amounts due in this case. Also, you will not be allowed to pay us by check for the next 6 months following the returned check. Patients in Collections - Patients with unpaid balances in collections will not be scheduled for appointments unless approved by the Billing Dept. Generally “Collections” balances must be paid in full before you can be seen here again. I hereby assign RMOM the right to bill and receive payment from my health insurances and authorize RMOM to release information to them for payment and audit purposes and provide access to my records to the necessary parties to accomplish this task and acknowledge understanding the above policies and procedures as a patient of Rocky Mountain Osteopathic Medicine (RMOM). __________________________________ _________________________________________ _____________ Printed Patient Name Patient or Guardian Signature Date


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