South Dayton
Acute Care Consultants Financial Policy
Thank you for choosing
Acute Care Consultants as your health care
provider. We are committed to building a
successful physician-patient relationship with
you. Your clear understanding of our Patient
Financial Policy is important to our
professional relationship. Please understand
that payment for services is a part of that
relationship. Please ask if you have any
questions about our fees, our policies, or
your responsibilities. It is your
responsibility to notify our office of any
patient information changes (i.e. address,
name, insurance information, etc). The
following is a statement of our “financial
policy.” Please read the information carefully
and sign where noted below.
Insurance Claims
As a convenience to our patients we will
verify your coverage and bill your insurance
carrier on your behalf. In order to properly
bill your claims we require that you disclose
all insurance information including primary,
secondary and tertiary insurance, as well as,
any change of insurance information. Failure
to provide complete insurance information may
result in patient responsibility for the
entire bill. Some services may not be covered
by your insurance plan. We do our best to
obtain benefit information prior to your
visit, but it is the insurance company that
makes the final determination of your
eligibility and benefits. If your insurance
does not pay for any of the services performed
at our office, you may be responsible for the
total balance of the non-payable services.
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.
If we are out of network with your insurance
company payment must be made at time of
service. We accept cash, check, money orders
or credit cards.
Co-Pays
All co-payments and past
due balances are due at time of check-in
unless previous arrangements have been made
with a billing coordinator.
If you come unprepared to pay your co-pay 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.
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. You may be
placed on a cash only basis following any
returned check.
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. If you have
specific questions regarding your insurance or
any other information about your account,
please feel free to call our Accounts Manager
at (937) 438-7672.
I have read and
understand the above Financial Policy of South
Dayton Acute Care Consultants. I agree to the
terms outlined in this policy and understand
my obligations regarding any charges incurred.
Signature:_______________________________________
Date:__________________________
(Signature
of Responsible Party)