Nova Medical & Urgent Care Center, Inc Financial Policy

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1 Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care possible in a cost effective manner. Our professional fees have been determined through careful consideration in addition to being reasonable and customary within our geographical area. We are pleased to discuss with you any concerns you may have concerning a bill. Payment in full is due at the time services are rendered. As a courtesy to our patients, we accept cash, personal check, money order, Visa, MasterCard, Discover and American Express. We also provide our patients the ability to pay for their accounts online at There, you may create an account on our patient portal. Our Billing phone number is (703) In order to achieve our goal of providing you with the best possible care, we need your assistance and your understanding of our financial policy: Things to bring with you to EACH appointment: Health Insurance Card(s) Drivers License Method of Payment Any referral required by your insurance plan Appointments: Please arrive for you appointments 10 minutes early; 15 minutes for new patients If more than 15 minutes late for your appointment, you may need to reschedule your appointment It is your responsibility to verify that the physician is currently under contract with your insurance plan and that you have obtained all necessary referrals BEFORE your scheduled appointment. (Failure to confirm this may result for any and all charges.) Please inform the receptionist of any demographic changes (phone number, address, insurance information, etc.). Failure to notify us immediately of any changes may result in you being responsible for any services not covered by your insurance carrier. Missed or Cancelled Appointments and other fees: If you are more than 15 minutes late for an appointment, you may be marked as a No Show. 24 hours notice is required to cancel and/or reschedule all appointments. Failure to do so will result in a $50 No Show fee. If 24 hrs notice is honored, a cancellation code will be issued for future reference. You will have 30 days to dispute a No Show fee. All co-pays are due at the time of service. Any co-pay not received at the time of service will result in a $5 processing fee. There will be a fee of $30 for any returned checks to our office. All balances are due prior to any further service provided by our office

2 In Network vs. Out of Network Insurance: Your insurance coverage and benefits are a contract between you and your insurance company and therefore all disputes must be handled between you and your insurance company. We are contracted with multiple insurers to accept assignment of benefits. If you have insurance coverage under a plan with which we do not have a contract, we will file a claim on your behalf and you will be responsible for any balance that your insurance does not pay. 48 hours notice is required to verify insurance benefits. Payment in full is due at the time services are rendered: Co-pays and co-insurance amounts, deductibles and all non-covered items and charges are the insured/patient s financial responsibility and are due during the check-in process. Failure to produce payment at check-in may result in your appointment being rescheduled. If you receive more than one type of service on the same day, you may be responsible for more than one co-pay. Any amount not covered by the insured/patient s insurance is due upon receipt of bill. Any outstanding balance may incur interest, in addition to the initial balance. As a courtesy to our patients, we gladly accept cash, check, money order, Visa, MasterCard, Discover, American Express and on-line payments. Failure to pay balances will result in discharge from the practice. Keeping a credit card on file: Please sign our Patient Pay Easy Consent form in order to keep a credit card number on file (the same process you would go through for hotels, rental cars, etc.) to be used for any unpaid balances. This could also be your flexible spending account card. Self Pay Patients: We will give you an estimate of what will be due at the time of service and payment for services is due at the time of service. This may not be the entire balance due as the final balance is not determined until all services have been reviewed by the coding staff and any laboratory services have been invoiced to Nova. You will be asked to sign a waiver stating you have no health insurance and will not be filing with any health insurance carriers. Failure to sign this waiver may result in cancellation of your appointment. Medicare/Medicaid Patients: Please make sure you have a full understanding of your benefits and what might be your responsibility if not covered by your insurance plan. Additional Paperwork: Any paperwork needed to be filled out by the physician will result in a $30 charge. 48 hours notice is required for all paperwork. Minor Patients: The parent(s) or guardian(s) accompanying a minor are responsible for providing current insurance information for the minor as well as payment in full for services provided. Parent(s) or guardian(s) must have an Authorization for Medical Treatment form signed each time minor arrives unaccompanied for an appointment

3 In compliance with HIPAA regulations, we are unable to discuss any details of service rendered or to produce an itemized statement for any parties that are not the patient, unless otherwise documented. Both parents/legal guardian(s) are responsible for payment for services rendered to the minor patient. It is not the policy of Nova to enforce court orders. Auto Accidents/Workers Compensation: Motor Vehicle Accidents (MVAs) will be filed to your health insurance as a courtesy to you as Virginia is a non-subrogation state. You may file separately to your auto insurance for reimbursement. Failure to receive payment within 30 days of the date of service may result in your responsibility to pay. Our office will send appropriate workers compensation claim forms for services rendered on your behalf. Please provide us with your health insurance information at the time of service, in the event a claim is denied. If a claim is still denied, we will expect payment in full upon receipt of the bill. Lab/Hospital Charges: Any service(s) provided by a lab or hospital is a contract between you and that lab or hospital. Any dispute with that lab or hospital should be handled with that lab or hospital and is not the responsibility of this practice. It is your responsibility to know which procedures your insurance will and will not cover at these facilities and to request an Explanation of Benefits (EOB) from your insurance carrier. Collections and Outstanding Balances: The provider reserves the right to charge interest on any account that has an unpaid balance. Any outstanding balance after 75 days of the date of service may be referred to an outside collection agency. Accounts referred to an outside collection agency or attorney may be subject to a collection fee of 33%, which will be added to the total balance at the time of write-off. All collection and/or attorney fees/interest are the responsibility of the patient. At the time the balance is referred to an outside collection agency, Nova no longer houses the account and is unable to discuss any issues with the patient. All correspondence must go through the outside collection agency. Patients with unpaid delinquent accounts or accounts which have been sent to collections will be discharged from our practice. Payment Plans: Our billing office will be happy to work with you in order to pay any balance due to our practice. Please contact our billing department at (703) option 2 to work out a payment plan with our practice. Please allow 5 business days prior to each due date for each payment to be received by our practice. Refunds: Refunds will be issued to the appropriate party. Patient refunds will not be processed until all active or past due charges are paid in full. Refunds less than $20.00 will not be issued unless requested by the patient

4 By signing this document, I,, have fully read and understand the financial policy of Nova Medical & Urgent Care Center, Inc. I hereby consent to allow Nova to reach me via: List preferred order of method of contact: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Please check this box if you give permission for Nova to text you Please check this box if you give permission for Nova to communicate with you via Best Number to reach you from 8am-5pm ( ) - Best Number to reach you after 5pm and weekends ( ) - I will cooperate with the billing department of Nova to ensure proper payment for my services. I understand that I will be responsible for any cost(s) associated with the collection of my account if I default on this agreement. I understand that the terms of this financial policy may be amended at any time without prior notification to me, the patient. In the event that the patient is a minor, I am the parent and/or legal guardian of said patient and agree that I am responsible for payment for all services render to the patient herein. Printed Name of Patient DOB Signature of Patient Printed Name of Parent/Guardian (if Patient is a Minor) Signature of Parent/Guardian (if Patient is a Minor) **Please return signed copy to the front desk. A copy of the policy is available upon request.** - 4 -

5 PATIENT EASY PAY CONSENT I authorize Nova Medical & Urgent Care Center, Inc to charge my: credit card / flexible spending card / health savings card (please circle one) for the balance charges not paid by insurance within 90 days, not to exceed $ Annually. Semi-monthly. Weekly. Per Visit. (s) of Service: / / to / /. I assign my insurance benefits to the provider listed above. I understand that this form is valid for one year unless I cancel the authorization through written notice to the health care provider. Cardholder Signature Printed Patient Name of Birth Cardholder Name Cardholder Street Address City State Zip Code Credit Card Number CVV code Exp Visa Mastercard American Express Discover Check Card Other - 5 -

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