Patient Financial Policies

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1 Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID Fax Thank you for choosing Diabetes & Internal Medicine Associates, PLLC (including The Osteoporosis Center) as your health care provider. We are committed to providing you with the best treatment possible. Payment of your bill is considered part of your treatment and your understanding of, and compliance with, our financial policies and procedures are important. The fees we charge are considered usual and customary for our area. We will do all that we can to aid you in receiving the maximum allowable benefit from your insurance company; you are ultimately responsible for your account. In order to insure that your insurance company pays your services promptly and completely, we have some requirements that reduce denials and patient liability. Please contact your insurance carrier prior to your first appointment with us and find out what your financial responsibility is for your visit. Providing us with accurate information will make both check in and check out more efficient for you and allow us to obtain the quickest response from your carrier. We ask you to take time to read and be familiar with our financial policies as well as your own insurance benefits. You will be asked to sign acknowledgement of receipt of this Financial Policy prior to treatment. Basic Policy: The patient is responsible for all medical bills in our office. It is the patient s responsibility to know their insurance contract benefits, assure collection of insurance payment to us and to negotiate with their carrier over any disputed claims. Patients without insurance (Self-Pay): Payment in full is due at the time of service, unless you make other specific arrangements with our Patient Account Representative in advance of service. New Patient First visit: If we are unable to verify your insurance plan eligibility & benefits of coverage; you will be expected to pay for your initial office visit & services in full that day. Demographic Verification: At the time of your initial and subsequent appointments at our office, you will be asked to update your demographic information with our Receptionist/Front Desk staff. Insurance Cards: You must present your insurance card(s) at the first appointment and may be asked at the time of any subsequent appointments so we may verify eligibility. You must notify us immediately if you lose coverage, change health plans or there are any changes affecting your eligibility or coverage. Referrals: Some health plans require a referral from a primary care physician to obtain our services, such as a diabetes specialist or bone density scan. These health plans will not pay for services rendered without a referral. It is your responsibility to obtain a referral prior to treatment. If you have not obtained the necessary referral, you may either reschedule your appointment or if allowed by your insurance company, sign a waiver agreeing to pay the visit in full. Co-payments, Deductibles and Co-Insurance: If your insurance plan requires a co-payment for office charges, payment will be collected on the date of service. Under your health plan you may also be responsible for deductibles and co-insurance and may be asked to pay a portion of that at the time of service. A $5.00 processing fee will be added to each visit for which you do not pay your portion or copay at the time of service. If you have not met the insurance plan s out of pocket expense (deductible) for the year, we will ask you to pay in full until your insurance carrier starts paying out benefits. If you have met your yearly deductible, we will ask you to pay that portion that your insurance carrier will not cover. If you do not know what portion you are expected to pay, we will ask for 20% of your charges for the visit s services that day. Refunds: If your insurance plan covers and pays more than expected, we will gladly issue you a refund check upon receipt of the insurance company s payment to us. Non-covered services: In the event that a service in our office is expected not to be covered by your Page 1 of 5

2 Patient Financial Policies cont. insurance, you will be asked to sign an Advanced Beneficiary Notice (ABN) holding you financially responsible for that service. Missed Appointments: will be noted in your medical record. We reserve the right to charge patient directly a fee of $25.00 for failure to call 24 hours in advance of a missed appointment. This fee is not submitted to your insurance carrier, but due directly from patient. Payment Methods: We accept cash, personal checks, and money orders, MasterCard & Visa as payment for services rendered. A returned check fee of $25.00 will be assessed to your account for every check returned for insufficient funds, stopped payment, or closed account. Balances for Previous Services: Prior to your scheduled appointment, our Patient Account Representatives will review your account and insure that your insurance company has processed your charges for previous services in accordance with your insurance plan. On or before your scheduled appointment, our Patient Account Representatives will discuss any balance on your account and assist you with payment arrangements. PPO Insurance Plans & Networks: Check with your insurance carrier to be certain that our company s providers are contracted with your Preferred Provider Organization (PPO) or specific network. We may not be! If we are NOT, your insurance plan may not pay the same rate as if a network provider saw you. If you are uncertain about our provider participation in your PPO or network, please first check with your plan or speak with our Front Desk staff. Insurance Claim Submission: Diabetes & Internal Medicine, PLLC s billing agent will submit the charges for your services to your primary and/or secondary insurance company on your behalf. We offer this service for you; however, you have selected your insurance plan and are ultimately responsible for proper payment. Secondary Insurance: We will submit your claim to your secondary insurance as a courtesy to you. You are responsible for any balances remaining after your insurance plans have responded to us. Monthly Statements: You will receive monthly itemized statements until your account is paid in full, whether or not you have insurance. We reserve the right to charge interest on past due accounts in the amount of 18% A.P.R as provided by state law. Collection: If you are responsible for some or all of the charges for our services, you will receive a statement after your health plan responds to our request for payment. We require payment in full or payment arrangements within 30 days after you receive your first statement. Our Patient Account Representative is available to review your account, please do not hesitate to contact us for assistance. Delinquent Accounts: Unpaid balances may be referred to a collection agency if other arrangements have not been made. Minor Patients: The adult accompanying a minor child is responsible for payment at time of treatment. Unaccompanied minors will be denied non-emergency treatment unless pre-authorized by a parent/legal guardian prior to service. Payment is still expected at time of service. Divorce Decrees: This office is not party to divorce decrees. Adult patients are responsible for their bill at the time of service. The financial responsibility for minors rests with the accompanying adult. Third-Party Billing: This office does NOT participate in any private third-party billing practices. Financial Hardship: If you were approved by an area hospital for Care Assurance or any type of charity program please provide proof of that approval and we will consider that approval for any related hospital charges. Contact Information: Our Billing Office agent can be reached at Please feel free to contact us with any questions or concerns. Date *(Patient/Responsible Party Signature) *Indicating that you have read and understand DIABETES & INTERNAL MEDICINE ASSOCIATES, PLLC Patient Financial Policies. Page 2 of 5

3 Assignment of Benefits and Release of Information MEDICARE (CMS) MEDICARE Assignment of benefits (Life time Signature on file until revoked in writing) I hereby authorize and direct that any Medicare benefits that may be payable as a result of treatment provided to me by Diabetes & Internal Medicine Associates be remitted directly to Diabetes & Internal Medicine Associates as they may request and direct. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services. Date (Medicare PATIENT S Signature) All Other Insurance Plans I hereby assign my insurance benefits that may be payable as a result of treatment provided to me by Diabetes & Internal Medicine Associates to be remitted directly to the physician/provider of Diabetes & Internal Medicine Associates as they may request and direct. I authorize Diabetes & Internal Medicine Associates to release any medical information about me to my insurance carrier and its agents as may be needed to determine these benefits or for benefits payable for related services. (PATIENT S Signature or Policy Holder s) Date Page 3 of 5

4 Office Patient Policies Appointments: I understand that I am to contact the office at least 24 hours in advance if I will be unable to keep my scheduled appointment, or as soon as is practically possible in the event of an emergency. Failure to do so may result in a $25.00 charge that I am personally responsible to pay; due from me and not my insurance carrier. I understand that it is best for me to arrive 10 minutes prior to my scheduled appointment to begin the check-in process which includes updating any changes in my demographics & providing copies of my current insurance card/s. I understand that Dr. DSouza may discharge me from his care and terminate our patient/physician relationship if I miss three (3) appointments without satisfactory cause or failure to contact office in advance. Patient Status: I am considered a patient of active status within this practice as long as I follow up with each recommended schedule of appointments and communicate clearly with the office staff if I am unable to keep appointments made. I understand that I must be seen at least annually or as my care plan prescribes in order to have any prescriptions refilled. I will actively follow medication, diet and treatment orders and instructions as prescribed. I will discuss any aspect of the treatment plan that I believe I cannot uphold and work with Dr. DSouza &/or his designated clinician to create/adjust my treatment plan accordingly. Consent to Treatment: I understand the nature and purposes of the healthcare services provided by Diabetes & Internal Medicine Associates and by my presentation to my appointments and active involvement in my proposed care plan; give consent to treatment as explained to me and as prescribed. Privacy & Security of Patient Health Information & Records: I have been offered and encouraged to read and understand Diabetes & Internal Medicine Associate s current version Notice of Privacy Practices Policy. I have been advised within the Privacy Practices Policy what safeguards & security are in place to protect my personally identifiable health information, how it may be used &/or disclosed in the processes of providing treatment, securing payment for that treatment and other health care related activities as defined in the Healthcare Information Portability &Accountability Act (HIPAA). Upon my written request I will be given a paper copy of my records as outlined in the Notice of Privacy Practices Policy, which I have been encouraged to review either in the office or on the practice s website Payment / Insurance: I will pay my co-payments, co-insurances and/or deductibles at the time of service. If I am a self-paying patient, I will make payment in full at time of service. I understand that the practice accepts cash, credit cards and checks as forms of payment. If my insurance plan requires a referral, I am responsible to obtain it from my primary care provider before my appointment. I know that the primary concern of this practice is my ongoing good or improving health, and I will not allow past due balances to interfere/interrupt with my course of treatment. Medications: I am responsible for making every effort to safely manage my prescribed medications. It is my responsibility to bring a current legible list of all my prescriptions with me to each appointment, regardless who prescribed them. It is my responsibility to advise my provider of any changes to my medication list made since my last visit. I may be asked to bring in my actual prescription bottles/containers. I understand that this practice cannot / will not authorize refills on lost medications, especially if the medication is a controlled substance, except under extremely rare special circumstances. I understand that it is my responsibility to call for prescription authorizations 48 hours in advance of running out of the medication. My pharmacy must contact this practice with my refill requests. This practice will call back requests between 8:45am 4:15pm Monday Thursday (I realize the office is closed on Fridays). In order to receive ongoing prescription medication, I understand that I must be evaluated every three months depending on my diagnosis OR at least once per year, unless other care plan arrangements have been made. If I am past due for an evaluation, I may be required to make an appointment prior to receiving a requested refill in order to ensure that my health condition is being properly monitored. Date *(Patient/Responsible Party Signature) * Indicating that you have read and understand DIABETES & INTERNAL MEDICINE ASSOCIATES, PLLC Office Patient Policies. Page 4 of 5

5 PATIENT CONSENT FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, Diabetes & Internal Medicine Associates, PLLC (including The Osteoporosis Center) (hereinafter referenced as DIMA) may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to our Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. DIMA reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to DIMA Privacy Officer at 2302 E. Terry St., Suite A, Pocatello, ID 83201, or can be obtained at forms. With my consent, DIMA physician & staff members may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, DIMA or its trading partners may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With my consent, DIMA may e- mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that DIMA restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to DIMA s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, DIMA may decline to provide treatment to me, until such time as accommodations can be made to existing policy on my behalf. Signature of Patient or Legal Guardian Legal Guardian Relationship Patient s Name (Print) Date of Signature Legal Guardian s Name (Print) Page 5 of 5

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