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PROGRESSIVE CARE FOR WOMEN'S PAYMENT POLICY
Please download the full copy of our payment policy, print, sign and bring it to your scheduled appointment.
If you are not able to print it, we will provide you with a copy of this form at the time of your visit.
There is a $50 cancellation fee for appointments cancelled with less than 24 hours notice.
Download Payment Policy Here
(You will need a free Adobe Acrobat Reader to open this PDF file. You can download it
here).
I hereby acknowledge the following payment policy of Progressive Care for Women (PC4W):
1. Payment of copays, patient portions and balances due are expected at the time that services are rendered.
2. New patients must pre-pay $35 to hold an appointment. This amount will be posted as paid on your account and applied toward any co-pays or patient portions of your bill. If you cancel or reschedule your appointment with less than 24 hour notice, the $35 will serve as a cancellation fee.
3. Patients must have an updated credit card on file to cover any charges as outlined below. Please note that your card will ONLY be charged after your authorization or for failure to respond to our billing statements.
4. PC4W will submit a claim for the current services to your insurance carrier. Insurance carriers are required to pay their portion of the claim within 45 days of receipt. When an insurance carrier is required to pay PC4W for a service that has been provided, you are only responsible for what is considered the patient portion of the claim. However, if your insurance carrier delays or withholds payment of its portion for more than 90 days from the date of service, both the insurance and patient portions of your account then become your responsibility. Our office policy is to automatically charge your credit card for any outstanding balance after your account becomes more than 90 days past due. If we subsequently receive payment from your insurance carrier, we will credit your account for the amount of the payment. We will also contact you and give you the option of receiving a refund.
5. After your insurance carrier pays its portion of the claim, you may be responsible for a patient portion, due to such factors as uncovered services, copayments or unmet deductibles, as outlined in your particular insurance plan. We will send you a billing statement outlining this patient portion. You will have 30 days from the date of the billing statement to submit payment for these charges, after which time we will automatically charge your credit card for the entire amount of the patient portion.
We strongly suggest that you monitor your account and the explanation of benefit forms that you receive from your insurer. You should resolve all disputes involving patient portions and explanation of benefits directly with your insurance carrier.
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