FINANCIAL POLICY

Gastrointestinal Associates' staff will do what they can to insure submission of primary and secondary insurance claims for its patients. The patient, however, is responsible to provide all the necessary insurance information to ensure the success of the claim and subsequent payment. Upon each visit, the patient will be asked to provide their cards.

OFFICE VISITS: All payment is due and must be paid at the time of the visit to the physician. Each patient will be expected to pay before they exit the office. Please sure that your plan coven your visit and Gastrointestinal Associates accepts your insurance. Additionally, all co-payments must be made at this time. Failure to pay at the time of your visit may result in possible discharge from the practice.

MEDICARE WAIVERS: Medicare will only pay for services that it determines to be "reasonable and necessary" under Section of the Medicare Law If Medicare determines that a particular service is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment of that service. Your physician may feel the service is in your medical interest, but you need to know that

Medicare is to deny payment and by signing this policy you agree to be and responsible for payment.

RETURNED CHECKS: A service charge of $30.00 for checks returned for non-sufficient funds will be charged to the patient. This will be paid prior to the next visit or within 30 days whichever comes first. Failure to make payment may result in possible discharge from the practice.

REFERRALS AND AUTHORIZATIONS: The patient is responsible for obtaining all referrals and authorizations prior to arriving for their scheduled appointment. The staff will assist in answering any questions that may arise from your insurance carrier, but the contact lies between you and your insurance company and therefore, you the patient, must obtain your authorization to be seen by the physician. Authorizations will not be obtained the day of your referral appointment, unless in the case of an emergency

APPOINTMENT NO-SHOWS/CANCELLATIONS: Any established patient who for their scheduled appointment will be required to pay $25.00 up front before scheduling a new appointment. Any new patient who no-shows for their scheduled appointment will be required to pay $50.00 up front before scheduling a new appointment. Any patient who no-shows for their scheduled procedure will be required to pay $100.00 up front before scheduling a new procedure. Upon showing up for the 2nd scheduled appointment or procedure, the patient will be refunded their money back and we will file their insurance. If the patient does not have insurance, the money will be applied towards that service. If the patient fails to show up for the 2nd scheduled appointment or procedure we will keep the down payment they provided us.

A 48-hour notice must be given to cancel any procedure and a 24-hour notice must be given to cancel an appointment. If the patient fails to provide the appropriate notice, the above policy will be enforced.

Any requests for special payment arrangements must be made prior to your visit. You will need to contact the Collections Manager to make special arrangements. They will not be made the time of your visit.

I certify that I have read and accept all terms set forth in this arrangement and I agree to pay Gastrointestinal Associates, P.A. for services rendered.

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