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.


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 $50.00.

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.