We are dedicated to providing you with the highest quality of healthcare. Beyond the practice of medicine, all healthcare providers are faced with the task of working with many different insurance companies who help coordinate your care and meet your medical financial responsibilities. By signing this form, you acknowledge your financial responsibility, including your responsibility to be aware of what your insurance does and does not pay for, as well as any patient responsibility amounts. We are happy to assist you in this process.
Retaining Credit Cards on File Our office requires retention of an active credit or debit card on file to bill any balances. Health Savings and Flexible Spending cards are acceptable forms of payment, though we will require an additional card on file in case the available funds on those cards have been exhausted. All credit card information is encrypted and stored securely.
Self-Pay Payment is due in full at the time of your appointment unless you have elected to pre-pay for services. We accept cash, check and credit card payments. There will be a $30 fee for a returned check.
Private Insurance We currently accept and process for participating Aetna, Blue Cross Blue Shield, and United Healthcare plans that cover acupuncture. We will also process when Medicare is primary and one of the aforenamed insurance providers is secondary. If you change insurance companies or employers, or your policy is updated or changed, you agree to provide this office with the current information immediately. If benefits are determined through your policy but you do not wish to process through your insurance, you have the option to sign an insurance waiver provided by our office and pay the self-pay rate instead.
Copays and Co-Insurance If you have a policy that identifies a flat copay or percentage-based co-insurance, we will collect the estimated patient responsibility at the time of service.
Deductible Patient Responsibility and Outstanding Balances Some services may not be covered by your insurance plan, may process to your deductible or may require an additional stated amount under patient responsibility. Your deductible is the amount your insurance company requires you to pay out of pocket prior to coverage. As a participating provider with your plan, all balances are due in full upon our receipt of Explanation of Benefits (EOB) from your insurance company, including deductible or additional copay, coinsurance or additional fees assigned to you by your insurance company. Any balances on your account from prior visits after insurance processing, are due at your next appointment or will be reconciled at the month’s end and charged to your credit card on file.
Worker's Compensation and Motor Vehicle Accidents/Personal Injury In a case where a third party may be liable for payment of your bills, you are responsible for your charges and we require payment in full at the time of service. We can provide you with a superbill insurance receipt upon request. We will not sign a Doctor’s Lien with your attorney. We are not permitted to bill your private insurance for these services unless subrogation has been identified in writing between your private insurance and your worker’s comp/personal injury insurance companies.
Office Records A $25 fee will be assessed for a compilation of your medical records.
Missed Appointments To ensure that the most people can receive care when needed, we require notification of any appointment changes 24 hours in advance of your appointment. A $50 fee will be assessed for any missed appointments or cancellations with less than 24-hour notice. Any cancelled/missed appointments are best to reschedule within the week to maximize your benefit of care and follow the treatment pan your Provider has outlined for you.
By signing this form, I have read, understand and agree to the financial policies of Holistic Health Associates.
