Complete & Compassionate OB/GYN Care
Financial Policy

Please PRINT this form and BRING it with you to your appointment.

Thank you for choosing Complete & Compassionate OB/GYN Care to assist you with your health care needs. We strive to provide you with the best care possible, and, in return, we ask that you assist us not only in monitoring your health care, but also by paying for our services in a responsible and timely manner.

The following is a statement of our financial policy. Our office requires that each patient read and sign a copy of this policy before we provide any treatment. Therefore, please read through this statement and feel free to ask us any questions you may have relating to our policy. Then sign the statement at the bottom of this form.

Acceptable Payment Methods:

We accept cash, checks, Visa, Mastercard, Discover Card and American Express. Under certain circumstances, with prior credit approval and an approved credit card, we do offer extended payment plans. If you need additional information on that, please talk to our billing staff.

Most insurance programs are accepted. Please see details below.

• Insurance: Our office accepts assignment of benefits from many insurance companies, hmo and ppo programs. However, we do not accept all benefit programs. Therefore, please inquire as to whether or not your insurance company, hmo or ppo (call them to make sure) is accepted by this office when taking into account what method of payment you will want to use.

  We do require that your co-payment or deductible be made at the time of service. In the event that we do not accept assignment of benefits from a particular insurance company, hmo or ppo, we require that you pay your bill in full at the time of each visit or be pre-approved on our extended payment plan.

• Your bill is your responsibility. If your insurance company or other benefit program doesn't cover the entire bill, it's your responsibility to pay the balance. Unless you are on an extended payment plan, we expect payment in full within 45 days of being notified of any balance due.

  Please be aware that some services provided may be non-covered services and are not considered reasonable and necessary under the Medicare Program and/or other insurance company, hmo or ppo, or other benefit programs. (Note: All laboratory tests, injections, ultrasounds, venipunctures, procedures, or any testing is not included as part of an office visit and will result in additional expenses.

• Adult Patients: Adult patients are responsible for payment at the time of service.
  Minor Patients: The adult accompanying a minor and the parents/guardian of the minor are responsible for the full payment at the time of service.

Usual and Customary Rates: We are dedicated to providing the best treatment for our patients and we charge what is usual and customary for our area of the country. You are responsible for payment regardless of any insurance company's (or any other benefit program's) arbitrary determination of what are usual and customary rates.

Missed Appointments: Our policy is to charge for missed appointments; those appointments that are not canceled at least 24-hours in advance. The charge is $50.00 (fifty dollars). Please help us serve you better by keeping all scheduled appointments.

I certify that I have read and understand the "Financial Policy" and agree to all terms and conditions as stated above. I understand it is my sole responsibility to verify my medical coverage with the insurance company, hmo or ppo, Medicare/Medicaid or other benefits programs and that I am ultimately responsible for payment in full for any outstanding balances incurred.

SIGNATURE: ____________________________________ DATE: ______________________