Thank you for choosing Acute Care Consultants as your health care provider. We are committed to providing the best possible care. Please understand that management of your billing is important in ensuring that we can continue to take care of your health care needs. The following is a statement of our “financial policy.” Please read the information carefully and sign where noted below.

Our policy is that payment is due at the time of service unless we are contracted with your insurance company or other arrangements have been made prior to your visit. We accept cash, check, money orders, Visa, MasterCard, Discover and American Express. As a convenience to our patients we will verify your coverage and bill your insurance carrier on your behalf. We provide insurance filing for primary, secondary and tertiary coverage’s. However, you are ultimately responsible for payment of your bill.

 Co-Pay and deductible policy: You are responsible for payment of any deductible and copayment/ co-insurance as determined by your contract with your insurance carrier. These must be paid at the time of check in.

 If you come unprepared to pay these amounts a fee of $10.00 will be applied to your account, or we may reschedule your appointment.

 Failure to meet your financial obligations could result in dismissal from our practice.

 Appointment cancellations require a 24-hour notice. Missed appointments without 24-hour notice are subject to a fee of $25.00.

 If you cancel your appointment with less than 24 hours notice or do not arrive for your appointment, the time reserved especially for you often goes unfilled, depriving other patients who need to be seen .

 Patients who have not paid this prior to the time of their next visit will need to pay this fee before being seen.

 Forms and Medical Records: We do charge for filling out forms and producing copies of medical records. These fees are available upon request.

 Return check policy: If a check is returned for insufficient funds a charge of $25.00 will be applied to your account.

 If you do not have insurance coverage, you will be expected to pay at the time of service. Please call our Accounts Manager prior to your visit if special arrangements need to be made.

 If we are not contracted with your insurance company and/or network you will be required to make payment in full at the time of your visit. Your insurance company will reimburse you directly. We will be happy to file your insurance claim. If you have a secondary or tertiary policy you will need to forward a copy of your Explanation of Benefits for further filing.

ACUTE CARE CONSULTANTS FINANCIAL POLICY

 If we are contracted with your insurance company and/or network the amount of your payment at the time of service will depend on your specific plan of coverage. Please check your plan payment schedule so you will know what you will be expected to pay at time of service. You are responsible for any amounts not covered by your insurer.

 PRIMARY CARE REFERRAL - If you belong to a managed care plan, your insurance company may require that you have a referral from your primary care physician. If your plan requires a referral it is YOUR RESPONSIBILITY to bring it with you at the time of your appointment. Without a referral your appointment will either need to be rescheduled or you will be expected to provide payment in full at the time of your appointment.

 We are providers for many insurance companies and networks. For specific questions regarding your insurance or any other information about your account, please feel free to call our Accounts Manager at (937) 438-7672.

Some services may not be covered by your insurance plan. Acute Care does their best to obtain benefit information prior to your visit, but there are no guarantees that all services will be paid by your insurance. Therefore, after we file your claim(s) and we receive the response from your insurance company, we will bill you for any unpaid balance that is annotated as patient responsibility. Payment in full is due upon receipt.