Patient Financial Policy Thank you for choosing PeaceHealth Medical Group as your healthcare provider. We are committed to provide each of our patients with quality health care in a way this is financially responsible for both our patients and our practice. Your clear understanding of our Financial Policy is important to our professional relationship. Insurance billing We participate in most major health insurance plans. As a courtesy to our patients, we will submit insurance claims to your carrier, however, we expect you to: • Be responsible for understanding the details of your insurance coverage, including preventative care benefits, requirements for pre-authorization for procedures, annual deductible and copay/coinsurance amounts. • Provide us with a current copy of your card and notify us of any changes in your insurance coverage. If we do not have current insurance billing information, we will expect full payment at the time of service. • Pay your copay at the time of service. Be responsible for any charges not paid by your insurance company within 45 days of our filing. No insurance or for visits/services not covered by your carrier, we expect you to: • • Pay in full at the time of service, unless prior arrangements have been made to accommodate a payment plan. When you pay in full at the time of service, we can offer you a “prompt pay” discount of 20%. An Advanced Beneficiary Notice (ABN) may be required to acknowledge your understanding of your responsibility of services not covered. Worker’s Comp or Accident Liability Claims • We ask that you notify our office in advance of your appointment so that we can verify coverage for your care. Please bring • copies of your insurance cards and all pertinent paperwork. If we are not able to verify coverage for your care under the worker’s comp or accident liability claim, we will expect full payment for services at the time of the visit and will honor our 20% prompt pay discount. Obstetrical Billing Insurance coverage: • • • We will verify coverage with your insurance carrier and estimate the amount of your out-of-pocket (OOP) costs after your initial visit. A payment plan will be arranged which will allow you to complete payment in full by your delivery date. Your maternity care fee will be billed to your insurance after your delivery. Included in this fee are all regularly scheduled prenatal visits, the delivery, and your six-week postpartum care. The maternity care fee usually does not cover diagnostic tests, ultrasound exams, amniocentesis, nuchal translucency, circumcision fees, or office visits unrelated to your pregnancy. Any non-covered service will become patient responsibility. No insurance coverage or no maternity benefits: • We require a $750 deposit at your initial OB visit. A monthly payment plan will be arranged which will allow you to complete payment in full by your delivery date. The site Healthcare Coordinator and/or your Business Office/ Insurance Verification team will gladly help you with verification of your benefits and payment plans. If your responsibility for the costs of maternity care is different from our estimate, we will refund any overpayment or bill you for any portion of your out of pocket expenses not yet paid. Minors The parent(s) or guardian(s) accompanying a minor are responsible for providing current insurance information for the minor and/or payment in full for services provided. Unaccompanied minors must have an authorization for medical treatment signed by a parent or guardian and is responsible for providing current insurance information for self and/or payment in full for services provided. Delinquent Accounts You will receive a monthly statement showing itemized charges and the total due on your account. • In the event that a patient stops making payment on his/her outstanding balance for longer than 45 days, he/she will be considered as having a delinquent account. • Before patients with delinquent accounts will be allowed to return for care, they must pay their entire balance in full. • Patients with outstanding balances may have their accounts forwarded to a collection agency after 90 days of nonpayment. • While we always see patients for emergency care, routine care will only be given to patients whose accounts are current or who have made financial arrangements with the business office and are maintaining the conditions thereof. Missed Appointments We would appreciate your help and the courtesy of a phone call if you are unable to keep your appointment. Please notify our office at least twenty four (24) hours prior to your appointment time. Returned Checks A $45 fee will be assessed to your account for each returned check. This fee and the original check amount must be paid in full with cash, credit card, or money order prior to your next appointment. After receiving two (2) returned checks, we will no longer accept checks as a method of payment. Billing Office Hours For your convenience, our Business Office is staffed Monday through Friday from 7:30AM to 5:00 PM. The phone number is (360)735-3500. Our knowledgeable staff will be happy to address any questions or concerns you may have regarding our financial policy or your account. Thank you for choosing PeaceHealth Medical Group. I have read the above financial policy. I have asked for clarification of the policy as needed and understand it fully. I agree to comply with the terms set forth in this policy for services rendered at any PeaceHealth Medical Group facility. Patient’s Name (please print)_____________________________________________________________ Signed________________________________________________ Date__________________________ (Patient or Person financially responsible for the bill)