Financial
Policy
Thank you for choosing North Coast Cancer Care, Inc. to meet
you specialized medical needs. Weare committed to providing you
with the best treatment available. Please understand that payment
of your bill is considered part of your treatment. The following
is a statement of our Financial Policy, of which we require that
you read and sign.
All new patients must complete our Patient Registration form
as well as our Financial Policy before seeing the physician.
PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE
FOR YOUR CONVENIENCE WE ACCEPT CASH, CHECKS, VISA, MASTERCARD & DISCOVER
PAYMENT PLANS ARE ACCEPTED UPON APPROVAL
REGARDING INSURANCE: Your insurance policy is a contract between
you and your insurance company. We are not a party to that contract.
We will bill your insurance plan for you, as long as you provide
us with the correct information. Please be aware that some, and
perhaps all, of the services provided may be non-covered services
and/or not considered medically necessary under your health insurance
plan. You, as the patient, ultimately are responsible for payment
of all services provided by our facility. While payment is your
responsibility, we will assist you in negotiating a settlement
with your insurance company for any disputed claim. Our Patient
Accounts Department is available to discuss any questions you
may have regarding your insurance or your account at 419-626-9191,
Monday through Friday from 8:00am to 12:00 pm and 1:00pm to 4:30pm.
Regarding insurance plans where we are a participating or preferred
provider: All copays and deductibles are due. In the event that
your insurance coverage changes to a plan where we are not participating
or preferred providers, refer to the above paragraph.
If you have a secondary insurance, we will bill it for you as
a courtesy, as long as you have provided us with the appropriate
information.
If you bill any insurance yourself, please do so promptly so
that you will receive reimbursement before your account is considered
delinquent.
MEDICAID PATIENTS: You are not responsible for any balances
due after Medicaid has paid unless Medicaid has you on a "spend
down." In order to be considered a Medicaid patient you
must present, at each appointment time, your Medicaid card that
is valid for the month in which you are receiving services.
USUAL AND CUSTOMARY RATES: Our practice is committed to providing
the best treatment for our patients, and we charge what is usual
and customary for our geographical location. You are responsible
for payment regardless of any insurance company's arbitrary determination
of usual and customary rates.
MEDICALLY NECESSARY CARE: We will only provide you with a service
if we consider it medically necessary. Therefore if your insurance
company arbitrarily detemines that a service we have rendered
to you is unnecessary, you will be responsible for the bill.
REFFERAL FORMS: It is imperative that, if you are covered under
an HMO or PPO health insurance plan requiring referrals, you
to contact your PCP and have their office make a referral to
us prior to your appointment. These referrals will authorize
you to see us, and your claim to be paid. If your plan requires
a referral to obtain your full benefits and you incur an out-of-pocket
penalty by not supplying one, you will be responsible for the
non-covered amounts connected to that visit. If you do not arrive
with a referral from and one is required for your visit or have
not had your PCP contact us prior to your visit with an authorization
number, your appointment may be re-scheduled for another date.
SELF-PAY PATIENTS: If you are non-covered by insurance, you
will need to see a Patient Accounts representative at your scheduled
appointment time. It is imperative that you speak with a representative
who may be able to offer you additional information of supportive
programs available to you directly.
CREDIT POLICY: Accounts are due and payable as of the date billed.
Unpaid balances will be considered delinquent after 120 days.
We realize it may be necessary on occasion to arrange installment
or other payment programs. If financial problems arise, please
do not hesitate to contact our Patient Accounts department as
soon as possible. .
If an account becomes past due with no valid reason, necessary
action will be taken to recover the account balance due.
Thank you for understanding our Financial Policy. Please let
us know if you have any questions or concerns.
I have read and received a copy of this Financial Policy. I understand
and agree to this Financial Policy. |
