FINANCIAL POLICY:



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FINANCIAL POLICY

Please take the time to read over and understand how this policy pertains to you. If you have any questions please ask our staff before signing.

We are on most insurance plans including Medicare, Tricare and Medicaid (for children). We are not contracted through some Medicare HMO.

Payment is due at the time of service: We require payment of co-pays, co-insurance or deductibles at the time of service. Our office collects according to your insurance company’s fee schedule and gladly accepts cash, checks, credit cards, Care Credit as well as HRA, HSA and FSA debit cards. If you choose to use your HRA, HSA or FSA debit cards and you do not have sufficient funds to cover your services, you will be asked to provide other means of payment. As a convenience to you we can also keep your credit card on file to pay out your monthly balances or financial payment arrangements.

For minor or young adult children who are not responsible for their own health care expenses please be prepared to send them with payment each time they are seen or leave a credit card on file for their monthly charges.

Patients with no insurance coverage: For patients without insurance our office can offer a self pay discount to make our care as affordable as possible. This savings is a result of reduced paperwork, less time spent filing insurance and determining medical benefits.

Financial Arrangements: Payment arrangements can be made with those who are unable to pay their full balance at the time of service by leaving your credit card information on file with us. This will give us permission to process monthly payments as agreed upon between you and our office. Your credit card information will be accessible by our collections department only and is locked up in a secure location. We also offer Care Credit as another option that offers you 6 months interest free financing.

Allergy Shots: Co-pays and coinsurance are required at the time of service.

Financial Need: In certain circumstances, we are able to provide reductions in balances due to financial difficulties. Please contact our office with any questions.

Insurance Cards: Each time you are seen please provide your most recent insurance cards to the front desk when arriving. Often a group number or claims address has changed from your last visit. If you have Medicaid or one of the Bayou Health Plans please inform us if you have other insurance in addition to this plan. If Medicaid or Bayou Health is unaware of your primary insurance you will be required to contact them to update this information before you can be seen. If you do not inform us of other insurance and Medicaid or Bayou Health determines you have other coverage and requests their payments made to us be returned to them, you may be responsible for any unpaid claims. Many insurance plans only give us 90 days to file a claim. If claims are not filed in a timely manner due to your failure to provide us with any updated insurance information you will be responsible for any unpaid balances.

Insurance Referrals: If your insurance requires a referral or prior-authorization for services, you are responsible for obtaining it. Failure to do so may result in a denial from your insurance company in which any unpaid balances will be your responsibility.

Medical Waivers: You will be required to sign a medical waiver as part of your initial paperwork where you are accepting financial responsibility for any charges incurred that are not covered by your insurance company. Medical waivers may also be required of you if your insurance company or Medicare considers the services we rendered as non covered.

Medicaid Patients: If Medicaid does not have primary or secondary insurance information on file, you will be required to reschedule your appointment until this information has been updated with the Medicaid office. You can contact the office at 877-204-1324.

Claims: All unprocessed claims greater than 90 days old will be the responsibility of the patient. If the patient is a minor, the financial responsibility relies with the parent or legal guardian who signs the financial policy. We see many patients who have a third party administrator that processes your claims. These third parties often do not have the funds to pay your claims. After 90 days if your claims have not been paid due to lack of funds, the balance of any unpaid claims will be billed to you.

Benefits: As a courtesy, we contact your insurance company to verify benefits. Benefits quoted by your insurance company are not a guarantee of payment and are sometimes misquoted. Benefits are determined once the claim is received and processed. If a claim is denied due to a billing problem with our office, we will contact your insurance company and resolve the matter. Our office will not be responsible for any disputes between you or your insurance company regarding deductibles, copayments, covered charges, or their interpretation of your medical necessity, or other denial. In all circumstances, you are fully responsible for all charges related to services provided by our office.

Returned Checks: A $30 returned check charge will be added to all returned checks.

Collections: Accounts with balances over 90 days will be turned over to our collection department. You will be responsible for all charges associated with the collections process including but not limited to collection fees, attorney costs and court costs. A 40% collection fee will be will be added to your outstanding balance.

Medical Forms and Patient Requested Letters: Fees vary according to the length and complexity of the form or patient-requested letter. Uncomplicated school forms are $15 per form. All fees are payable at the time of service.

No Show Policy: Due to an increasing number of patients who do not show for their appointments and who do not call in advance to cancel their appointments, we have issued a "no show" policy. This policy does not apply to those that contact our office to reschedule their appointments.

• After the first no show, the patient will be called as a reminder that the appointment was missed and will be asked if they would like to reschedule their appointment.

• Second and subsequent no shows may result in us not rescheduling your appointment.

• We call and try to confirm all appointments prior to your visit, however on rare circumstances this may not be possible, mostly due to incorrect or disconnected telephone numbers. Please set yourself a reminder.

Please contact us if you are having difficulty meeting your payment obligations. If you do not communicate with us, we cannot work with you in working out a payment agreement.

I acknowledge that I am fully responsible for payment of all charges that I incur at the Allergy, Asthma & Immunology Center of SWLA.

Patient Name: ___________________________________ Date: __________________

Signature of Patient of Legal Guardian: __________________________________________________

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