Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
350 CONGRESS PARKWAY, SUITE E, CRYSTAL LAKE, ILLINOIS 60014
27750 WEST HIGHWAY 22, SUITE 105, BARRINGTON, ILLINOIS 60010 PHONE 815-477-8900 FAX 815-477-7160
RAJA SHARMA, MD, FACC, FSCAI JOEL D. ROBBINS, MD, FACC, FSCAI
JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC
IllinoisCardiovascularSpecialistsFinancialPolicy
ThankyouforchoosingGlobalCareS.C.(dbaIllinoisCardiovascularSpecialists)asyourhealthcareprovider.Weknowyouhaveachoicewhenchoosingyourmedicalproviderandhopethatwemeetyourexpectations.Aclearunderstandingofourpatientfinancialpolicyisimportanttoourprofessional
relationship.Pleaseunderstandthatpaymentforservicesispartofthatrelationship.Pleaseaskusifyouhaveanyquestionsaboutourfees,policies,oryourresponsibilities.Itisyourresponsibilitytonotifytheofficeofanypatientinformationchangessuchasaddresschanges,namechangesorchangesin
insuranceproviders.
Co-PaysThepatientisexpectedtopresentaninsurancecardateachvisit.Allcopaymentsmustbepaidatthetimeofservice.Therewillbenoexceptionsforthis.Ifacopaymentcannotbemadeourprovider
cannotseeyouthatday.
Self-paypatientsSelf-paypatientswillberequiredtopay$250foranyinitialconsultationand$175dollarsforanysubsequentvisits.Anyremainingbalancewillbebilledtothepatient.
Referralsandpre-authorizationsDuetothemanychangesininsurancepoliciesitisnolongeraneasy
tasktointerpreteachindividualpolicy.Itisyourresponsibilitytoknowyourindividualpolicy.CertainhealthinsurancessuchasHMOsrequirethatyouobtainreferralfromyourprimarycareproviderbeforevisitingaspecialist.IfyourInsurancecompanyrequiresareferral,youareresponsibleforobtainingit.
Failuretoobtainareferralcouldresultinthepatientbeingresponsibleforallcostsincurred.Wewillbeunabletoseeyouifyoudonotproperlyobtainareferral.Pre-authorizationwillbeobtainedbyourofficeforanytestingorderedbyourphysicians.Understandthatpre-authorizationisnotaguaranteeof
payment.Youareultimatelyresponsibleforpaymentofservicesrenderedifyourinsurancecarrierdoesnotpayforanyreason.
PaymentbalancesInordertoprovideahighlevelofserviceandtocontinuetorunourindependentpracticeweexpectfull
paymentatthetimeofservice.WeacceptmanyinsuranceplanscurrentlyofferedintheChicagoArea.Itisourresponsibilitytoaccuratelyandquicklybillyourinsuranceprovider(s)onyourbehalf.
Ifapatients’balanceafterinsuranceremittanceis$250orless,weexpectfullpaymentwithin30daysofsendingyouabillingstatement.Ifapatients’balanceafterinsuranceremittanceisgreaterthan$250
weexpectatleasta$250paymentwithin30daysofyourbillingstatement.Anyremandingbalancewill
350 CONGRESS PARKWAY, SUITE E, CRYSTAL LAKE, ILLINOIS 60014
27750 WEST HIGHWAY 22, SUITE 105, BARRINGTON, ILLINOIS 60010 PHONE 815-477-8900 FAX 815-477-7160
RAJA SHARMA, MD, FACC, FSCAI JOEL D. ROBBINS, MD, FACC, FSCAI
JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC
beexpectedtobepaidoffinfullwithin6monthsofthefirstbillingstatement.Wewillrequireavalid
creditcardonfileandyourcardwillbechargedmonthly,afterthefirst3monthsbalancesthathavenotbeenpaidinfullwillincuramonthlynon-adjustableservicechargeof$20.Accountsnotpaidinfullafter6monthswillbeturnedovertoalicensedcollectionagencyandwillbesubjecttoanyapplicable
placementfees.Atthatpointthepatientmostlikelywillbedischargedfromthepractice.
MissedappointmentsIllinoisCardiovascularSpecialistrequires24-hournoticeofappointmentcancellation.Appointmentsmissedandnotpreviouslycanceledmaybechargedafeeof$50.00.
Returnedchecks
Thechargeforreturncheckis$35dollarspayablebycashormoneyorder.Thiswillbeappliedtoyouraccountinadditiontotheinsufficientfundsamount.Youmaybeplacedonacashonlybasisfollowinganyreturnedcheck
Thisfinancialpolicyhelpstheofficeprovidequalitycaretoourvaluedpatients.Ifyouhaveany
questionsorneedclarificationofanyoftheabovepolicies,pleasecontactoraskus.
Fees:
Cancellation/Reschedulelessthan24hrs$50.00
Noshowforappt$50.00
Lexiscan/MyoviewStresstestCancelationlesstan24hrs/useofCaffeine$250.00
Returncheckfee$35.00
FMLA/Disabilityforms/workreleasePaperwork/Forms$50.00
MedicalRecordsBaseduponIllinoisStateGuidelines
____________________________________________________________________
(Patient/GuardianSignature)Date