Practice Financial Policy

Payment Options if you have no insurance: Unless other arrangements have been made in advance, full payment is expected at the time services are rendered.

1. Forms of payment include; Cash, Checks, Visa, and Mastercard.

2. Special Financing through CareCredit can be obtained. (Ask our billing department for details.)

Payment Options if you have insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract in most cases.

If we are NOT contracted with your carrier full payment is expected at the time services are rendered. We will file your claim as a courtesy to you and payment will be sent directly to insured.

If we ARE contracted with your insurance carrier, the following applies;

1. Copay's: will be collected PRIOR to your visit. Failure to meet copay requirements may result in the rescheduling of your appointment.

2. Deductibles and Co-insurance: If your insurance has a deductible that has not been met and/ or a percentage that is patient responsibility, this amount is expected at the time services are rendered.

3. Referrals and or Prior-authorization: If your insurance company requires that you have a referral and/or prior authorization, you are responsible for obtaining it. Failure to obtain the referral or authorization may result in a lower payment from your insurance company, making you responsible for payment in full.

4. Non Covered Charges: Should your insurance company determine a charge to be non covered, you are responsible for full payment of the said charge.

5. Cosmetic Procedures: Insurance companies will NOT pay for cosmetic procedures. Payment for these procedures will be collected PRIOR to the scheduled surgery date.

Workers Compensation: We require written approval/authorization by your employer and/ or worker's compensation carrier PRIOR to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient's responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.

Divorce: In the case of a divorce or separation, the party responsible for the account prior to the divorce or seperation remains responsible for the account. After a divorce or seperation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.

Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer's fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Washington County, Virginia.

Returned Check Charge: There is a fee of $25.00 for any checks returned by the bank.

Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.

Transferring of Records: You will need to request in writing, and pay a reasonable copying fee of $15.00, if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information , including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant informaton, including your payment history.

Refunds: In the event of an overpayment on an account, a refund will be issued in the first bill pay following the posting of the credit. If the credit is under $10.00 the credit will remain on the account to be used at next visit.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

Print Patient's Name:____________________________________Date:___________

Signature:_________________________________Date:___________

(Responsible party)

Assignment of Benefits: I authorize payment of benefits from my insurance company to be paid directly to Abingdon Ear, Nose and Throat Associates, PC. I also authorize Abingdon Ear, Nose and Throat Associates, PC to release to my insurance company any and all information necessary for the processing of insurance claims.

Signature______________________________Date:______________

Witness: _____________________________ Date________________

Enter the Patient Portal to complete patient registration forms, medical history and access documents.

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Abingdon ENT is proud to welcome Mary Hinchey, AuD to our practice. She is now seeing patients at our Abingdon location.

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