Thank you for choosing us as your health care provider. We trust that you will feel warm, comfortable and secure with the medical care you receive. The following is a brief description of our financial policy.
Insurance: We participate with many insurance plans, including Medicare. As a courtesy to our patients we will bill your insurance provided we have your current insurance information. It is your responsibility to inform us of any insurance changes in a timely manner.
Payments: Fees which are payable at the time of service include: insurance co-pays, deductibles, noncovered services or charges for patients who have no insurance coverage. Because co-pays are an insurance requirement, we cannot bill you for these. We accept cash, checks or Visa/Mastercard. If for any reason you have paid by credit card and require a refund, our practice will typically refund the credit card directly.
Obstetrical Care or Surgery: For patients requiring Obstetrical Care or Surgery your insurance benefits will be verified and any precertification needed will be completed. Any deductibles, co-pays, or coinsurance is the patient's responsibility. In the case of elective surgeries, any amount that is deemed patient responsibility must be paid prior to the surgery. For obstetrical patients a payment plan will be prepared for you.
Returned Checks: There is a $40 returned check charge for checks returned for non-sufficient funds or any other reason. The fee, as well as the original amount, is due in our office within 10 days after notification. If the amount owed is $50 or more and we do not receive payment within 10 days, we reserve the right to turn this bad debt over to the Jackson County prosecutor's office.
Short-term Disability forms, Leave of Absence and/or Family Medical Leave Act (FMLA) forms: We require a prepayment of $20 for the completion of each set of Short-term Disability forms, Leave of Absence and/or Family Medical Leave Act (FMLA) forms. Please allow 5 working days for the completion of these forms.
Missed Appointment Fee: We understand that there may be situations that prevent you from keeping your scheduled appointment. If you are unable to keep your appointment we expect you to call with at least a 24 hour notice or you may be charged a no-show fee of $50. This fee must be paid before a new appointment is scheduled.
Monthly Statement: If you have a balance on your account. we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.
Past due account: If your account becomes past due, you have received two statements, and owe a balance of $25 or more we reserve the right to terminate the availability of our services to you until this balance is paid in full. If you owe a balance of more than $50 we will refer your account to a collection agency. If you have not paid the collection agency within 30 days of notice, they will report this to the Credit Bureau.
Assignment of Benefits/Medical Release: With my consent, Independence Women's Clinic may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations. I also assign to the physician all payments for medical services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by insurance.