GULF COAST FACIAL PLASTICS AND E.N.T. CENTER

FINANCIAL POLICY

Thank you for choosing Gulf Coast Facial Plastics and ENT Center as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.

All patients must complete our information and insurance form before seeing the Doctor.

· PAYMENT OF YOUR PORTION IS DUE AT TIME OF SERVICE

· WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD/AMERICAN EXPRESS

· WE DO NOT BALANCE BILL FOR PATIENT CO-PAYMENTS OR DEDUCTIBLES

It is our desire for you to be as well informed as possible of the cost associated with your treatment at our Facility.

Regarding Insurance:

We may accept assignment of insurance benefits. When provided with your insurance cards and information, we will file your insurance as a courtesy to you. You are, however, responsible for 100% of the charges should your insurance deny or default in any way. At the time of your visit, we will require you to pay the percentage of co-payment or cost share according to your policy.

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 60 days, the balance will be automatically transferred to you for payment.

Please be aware that some or perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medial insurance.

Managed Care Insurance Plans:

There are numerous managed care contracts in our area. Please be certain to ask if your specific plan is one for which we are a “participating provider”.

If your plan requires Referrals or Authorizations we must have a copy of that documentation before you can be treated.

Your cost share or co-payment will be due at the time of treatment.

Usual and Customary Rates:

Our charges are based on what is usual and customary for this area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Minor Patients:

All minor patients must be accompanied by a parent or legal guardian. That person is responsible for full payment. Please do not ask us to bill an ex-spouse for services rendered to a minor child.

Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns.

I HAVE READ, UNDERSTAND, AND AGREE TO THIS FINANCIAL POLICY.

_____________________________________ _____________________________

(Signature of Patient or Responsible Party) Date