Independence Women's Clinic

Financial Policy


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.

I have read and understand the financial policy of Independence Women's Clinic.

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