PriviaFinancialPolicy&NoticeofPrivacyPracticesEffective:February2018

FinancialPolicyWelcometoPriviaMedicalGroup!Wearepleasedthatyouhavechosenusasyourhealthcareprovider.Ourmissionistoprovideyouwiththehighestlevelofprofessionalmedicalcarewiththehighestdegreeofpatientsatisfaction.Toavoidanymisunderstandingsandensuretimelypaymentforservices,itisimportantthatyouunderstandyourfinancialresponsibilitieswithrespecttoyourhealthcare.WerequirethatallpatientssignourAuthorizationandConsentforTreatmentFormbeforereceivingmedicalservices.Thisformconfirmsthatyouunderstandthattheservicesprovidedarenecessaryandappropriate,andadvisesyouofyourfinancialresponsibilitywithrespecttoservicesreceived.

PATIENTRESPONSIBILITYPatientsortheirlegalrepresentativeareultimatelyresponsibleforallchargesforservicesprovided.Weexpectyourpaymentatthetimeofyourvisitforallchargesowedforthatvisitaswellasanypriorbalance.Someinsuranceplanstellusexactlywhatyouwilloweatthetimeofyourvisit;inthatcase,wemayrequestfullpaymentforyoursharewhenyoucheckinorout.Otherinsuranceplansdonotprovideimmediateinformationregardingpatientresponsibility;inthatcase,youwillbeaskedtosaveacreditcardonfiletosettleyouraccountorpayadepositwhenyoucheckinorout.Ifyousaveacreditcardonfile,wewillchargeyourcardforthebalanceduewhenyourinsurancecompanynotifiesusofyourpatientresponsibility.Whenyoumakeadeposit,youwillpayanestimateoftheexpectedpatientresponsibility;whenyourinsurancecompanynotifiesusofyourpatientresponsibility,wewilleithersendyouastatementforthebalancedueorissuearefund.IfyouhaveanAnnualWellnessVisitorPhysicalExambutneedadditionalservices,wemaybillyouforthoseadditionalservices.Allservicesforpatientswhoareminorswillbebilledtothecustodialparentorlegalguardian.Ifyoudemonstratefinancialneedandcompletetherequiredpaperwork,financialassistancemaybeavailable.Ifyouhavealargebalance,paymentplansmaybeavailable.TYPESOFPAYMENTS1.Co-payments.Insurancecarriersrequirethatwecollectyourco-paymentatthetimeofyourvisit.Ifyouarenotpreparedtomakeyourco-payment,youmayrescheduleyourappointment.2.Deductibles.Mostinsuranceplansrequireyoutopayapredeterminedamount(the“deductible”)beforeinsurancewillcovercertaincharges.Ourtechnologyallowsustoviewyourremainingdeductibleandhelpyouunderstandwhatyouwilloweforyourvisitsowecancollecttheamountdueatthetimeofyourvisit.Fornewpatientswhohavenotyetmettheirdeductible,wemaycollectupto$125.00;forestablishedpatients,wemaycollectupto$75.00.Thispaymentwillbeappliedtoyourvisit.Whenyourinsurancecompletesprocessingofyourhealthinsuranceclaim,youmayberesponsibleforanadditionalamountdependingonourcontractwithyourinsurer.NOTE:IfyoutakeadvantageofourCardonFileprocess,youwillnotberequiredtopayadepositatthetimeofyourvisit.3.Co-insurance.Someinsuranceplansrequirethatyoupayacertainpercentage(forexample,20%)oftheallowablechargeamount.Ourtechnologyallowsustoviewthedetailsofyourinsuranceplan,includingyourcoinsuranceamount,andcalculatetheexpectedout-of-pocketcostforyou.Ifwecandeterminetheamount,wewillaskthatyoupayyourco-insuranceatthetimeofyourvisit.4.UninsuredPatients/Self-Pay.Ifyoudonothaveinsuranceoriftheservicesprovidedarenotcoveredbyyourinsurance,paymentforallservicesisdueatthetimeofyourvisit.Twooptionsareavailable:1)apromptpaydiscountisavailableifyoupayinfullatthetimeofservice;or2)wecanbillyouifyoudonotpayatthetimeofservice.Ifthetotalchargeamountisnotavailableatthetimeofcheckout,youmayberequiredtopayadepositthatwillbeappliedtoyourcharges.Ifthedepositexceedsactualchargesthenarefundwillbeissued.NOTE:IfyoutakeadvantageofourCardonFileprocess,youwillnotberequiredtopayadepositatthetimeofyourvisit.

PriviaFinancialPolicy&NoticeofPrivacyPracticesEffective:February2018

Depositamountsare:•Newpatients:totalchargeoraminimum$200deposit.•Establishedpatients:totalchargeoraminimum$150deposit.•Procedures:totalchargeoraminimum$200payment

5.Out-of-Network.Weparticipatewithmostmajorinsuranceplans.Youcancontactyourinsurancecompanytoconfirmifyourproviderisinnetworkpriortomakingyourappointment.Ifwedonotparticipatewithyourinsuranceplan,youwillberequiredtopayforyourvisitatthetimeofservice.Wemaysendacourtesybilltoyourinsurancecompany.Ifthetotalchargeamountisnotavailableatthetimeofcheckout,youmayberequiredtopayadepositasdescribedabove.6.Non-CoveredServices.Itisyourresponsibilitytocontactyourinsuranceplantodeterminewhetheraparticularserviceiscovered.Ifweprovideyounon-coveredservices,youareexpectedtopayfortheservicesatthetimeofyourvisit.Ourbillingstaffwillassistyouinattemptingtoresolveanyappeals.IfyouareaMedicarepatient,wewillinformyouofanynon-coveredservicespriortoyourtreatment.YourproviderwillreviewoptionswithyouanddocumentyourdecisionandacceptanceoffinancialresponsibilityusingtheCentersforMedicareandMedicaidServices(CMS)formCMS-R-131(03/08),AdvanceBeneficiaryNotice(ABN).INSURANCEWeaskallpatientstoprovidetheirinsurancecard(ifapplicable)andproofofidentification(suchasaphotoIDordriver’slicense)ateveryvisit.Ifyoudonotprovidecurrentproofofinsurance,youmaybebilledasanuninsuredpatient(i.e.,self-pay).Ifyouprovideyourinsurancecard(s)atalatertime,wemaybeabletoretroactivelybilltheservicestoyourinsurerdependingontheinsuranceplan’srequirements.Weacceptassignmentofbenefitsformanythirdpartycarriers,soinmostcases,wewillsubmitchargesforservicesrenderedtoyourinsurancecarrier.Youareexpectedtopaytheentireamountdeterminedbyyourinsurancetobethepatientresponsibility.Ourfeesareforphysicianservicesonly;youmayreceiveadditionalbillsfromlaboratory,radiology,orotherdiagnosticrelatedproviders.Youareresponsibleto:

• Knowifareferralorauthorizationisnecessaryforofficevisits.(Ifitisrequiredandyoudonothavetheappropriatereferralorauthorization,youmaybebilledasanuninsuredpatient).

• Checkwithyourinsuranceplantodetermineifprescribedtesting(lab,radiology,etc.)iscoveredunderyourinsurancepolicy.(Ifyouchoosetohavenon-coveredtesting,wewillrequirefullpaymentatthetimeofyourvisit.)

• Checkwithyourinsuranceplantoreviewthescheduleofbenefitsandwhetheraco-paymentordeductibleapplies.

• Fileanyappealswithyourinsuranceplan,ifneeded.• Coordinatebenefitsifyouhavemorethanoneinsuranceplan.Youmayberequiredtocontactyour

insurancecompanytoclarifywhichplanisprimaryortocorrectanydemographicorotherissues.• Arriveforappointmentswithallrequireddocumentation.

InsuranceVerification.Wewillattempttoverifyyourinsuranceeligibilitytwo(2)businessdayspriortoyourvisit.Ifweareunabletoconfirmactiveinsurancecoverage,wewillcontactyouaboutyourinsuranceeligibility.Ifyouareunabletopresentanalternativeformofactiveinsurancecoveragepriortothevisit,youwillberequiredtoeitherpayatthetimeofyourvisitorrescheduleyourappointment.Forsamedayappointments,wewillcheckeligibilitywhentheappointmentismade.OutstandingBalances.Afteryourvisit,wewillsendyouastatementforanyoutstandingbalances.Alloutstandingbalancesaredueonreceipt.Ifyoucomeforanothervisitandhaveanoutstandingbalance,wewillrequestpaymentforboththenewvisitandyouroutstandingbalance.Youroutstandingbalancescanbepaidconvenientlyviaourpatientportal.Wegenerallysendstatementseverytwenty-eight(28)days,beginningwhenthebalancebecomespatientresponsibility.Ifyouhaveanoutstandingbalanceformorethanninety(90)days,youmaybereferredtoanoutsidecollectionagencyandchargedacollectionfeeof$25orwhateveramountispermittedbyapplicablestatelawinadditiontothebalanceowed.Inaddition,ifyouhaveunpaiddelinquentaccounts,wemaydischargeyouasapatientandyoumaynotbeallowedtoscheduleanyadditionalservicesunlessspecialarrangementshavebeenmade.

PriviaFinancialPolicy&NoticeofPrivacyPracticesEffective:February2018

LATEARRIVALS,CANCELLATIONS,ANDNO-SHOWSLatearrivals.Ifyouarrivelateforascheduledappointment,youmaybeaskedtorescheduleyourappointmentorwaitforanopenappointmenttimeonthatday’sschedule.Cancellations.Ifyouareunabletokeepascheduledappointment,youmustcallatleastone(1)businessdayinadvanceorwemayconsideryoua“no-show.”No-shows.Ifyoumissyourappointment,youmaybechargeda$50.00feeforamissedappointment,a$75.00feeforamissedpediatricappointment,a$100.00feeforamissedphysical,ora$200feeforamissedprocedureorsurgery.Thisfeewillneedtobepaidpriortorescheduling.Thisfeecannotbebilledtoinsurance.Aspermittedbystatelaw,youmaybedischargedasapatientfollowingthree(3)no-showsinaone-yearperiod(365days).CARD-ON-FILEPROCESSWhenyoucheckintoahotelorrentacar,youarerequiredtoprovideacreditcardtocoverthecostofanyincidentalchargesand/orpayyourbill.Thisprocessbenefitsbothyouandthehotelorrentalcompanybymakingthecheckoutprocesseasier,faster,andmoreefficient.WehaveimplementedasimilarprocessatPrivia.Youwillberequestedtoprovideacreditcardwhenyoucheck-inforyourvisitandwewillscanthecardintooursystem.Theinformationwillbeheldsecurelyuntilyourinsurancehaspaidtheirshareandnotifiedusofanyadditionalamountowedbyyou.Atthattime,wewillnotifyyouthattheremainingbalanceowedwillbechargedtoyourcreditcardfive(5)daysfromthedateofthenotice.Youmaycallourofficeifyouhaveaquestionaboutyourbalance.Wewillsendyouareceiptforthecharge.The“Card-on-File”programsimplifiespaymentforyouandeasestheadministrativeburdenonyourprovider’soffice.Thisreducespaperworkandultimatelyhelpslowerthecostofhealthcare.YourstatementswillbeavailableviayourpatientportalandourCustomerSupportlineisavailabletoansweranyquestionsaboutthebalancedue.Ifyouhaveanyquestionsaboutthecard-on-filepaymentmethod,pleaseletusknow.Thankyouforhelpingusrunabetterpractice!