Office Financial Policy
This office files insurance claims as a courtesy to our patients. This does not relieve the patient of their financial duty. All balances are the patient's responsibility and are due at the time of services rendered. You agree that you are responsible for all charges accumulated for services rendered to you regardless of insurance payment.
Our office policy on payment is as follows:
- All co-pays, deductibles, and other charges are due at the time of service.
- No one is allowed to have a patient portion of their balance greater than $150.00.
- Your account must be in good standing in order to continue with your treatment for your condition. (Emergency and life threatening conditions are exceptions).
- Any person with an account not in good standing will be denied services until the account is brought into good standing.
- All accounts that are 90 days past due will be sent to collections for processing. It will be reported to all credit bureaus.
Payment can be arranged in the following manner:
- Cash, Credit, Debit, or check will be accepted at time of service.
- Payment plans are available through the following options:
- Care Credit
- Chase Bank
- Monthly or weekly payment options only if a credit or debit card is on file. There will be no monthly payment options greater than 6 months in length.
- Pre-payment of account in full will result in 10% accounting discount.
All insurance and personal injury claims are the responsibility of the patient regardless of payment, non-payment, or outcome of case. Services rendered will be charged to the patient and paid in full.
I understand and agree with the financial policy of Advanced Spine, Sports & Rehab. I also understand that I am responsible for all charges rendered for services received in the office or for outside testing. I agree to pay these charges in full and keep my account in good standing.
Patient Signature____________________________________ Date___________