ASSIGNMENT AND AGREEMENT TO PAY
- As a courtesy, we will submit claims to all insurance carriers if we have received verification of insurance coverage. You agree to assign benefits of insurance policies and have payments made by those policies to The Center; however the patient remains responsible for all charges.
- Payments and outstanding balances including co-payments, deductibles, deposits, and prepayments are due at the time of service. We accept cash, checks, debit and credit cards; including VISA and MasterCard. Patients without evidence of insurance coverage are required to make a $150.00 deposit at the time of the appointment.
- A physical address may be required by your insurance carrier to process certain claims. If you do not provide a physical address you will be responsible for payment of all services provided.
- Any balance remaining after your insurance plan processes your claim with partial payment or denial, will be your responsibility. Payment is due within 30 days of receiving a statement from our office. If no payment received after 120 days, the account will go to collections.
- For purposes of collecting payments due, The Center, including outside parties such as billing services, collection agencies, and/or attorneys, may attempt to contact you using regular mail, email, text, MyChart messages, cell phone, and/or home phone.
- For Motor Vehicle Accident and Workers Compensation claims, you agree to provide your private insurance information at the time of your first visit. We will bill your private insurance for any denied or unpaid claims.
- For surgeries or procedures, your estimated portion will be collected prior to your surgery date. We will collect 50% of the surgery/procedure cost or 50% of your deductible for the Center’s fees.
SCHEDULED APPOINTMENT TIMES / NO SHOW FEES
- Given the overwhelming demand for care in our community, we encourage all patients to keep their appointments and arrive at the scheduled arrival time and location. As a courtesy to our other patients, we reserve the right to reschedule your appointment if you arrive more than 10 minutes late for your appointment.
- In the event you are unable to keep an appointment, you agree to provide at least 24 hours notice for any scheduled appointment and 72 hours notice for any scheduled procedure. Any visit not canceled or rescheduled within these timeframes will be considered a No Show and may result in a No Show fee. Continued No Shows will result in you being discharged and no longer eligible to receive care at The Center.
CODE OF CONDUCT
- The following are prohibited on the premises of The Center in order to ensure the safety and security of all patients, staff, and visitors at The Center; weapons, illegal or dangerous Items, alcohol, tobacco, and illicit drugs.
- The following behaviors are not acceptable; discriminatory, disruptive, disrespectful, or harassing language or actions including but not limited to:
- Offensive remarks regarding race, national origin, ethnicity, religion, sex, gender, gender identity or expression, sexual orientation, age, disability, military, or immigration status.
- Physical or verbal threats and assaults.
- Sexual, vulgar, or other unwanted remarks or actions.
- Disrupting the care or experience for patients and staff on the premises.
- Refusal to follow policies, guidelines, or staff instructions related to your care and treatment.
- As a patient of The Center if you violate this Code of Conduct, you will be discharged and no longer able to receive care at The Center.
- If your family member, caregiver, or other visitor of The Center violate this Code of Conduct, you will be asked to leave the premises and future visitation may be restricted.
