Financial Policy  
  FMC Health Network  
     
Welcome to Family Medicine Centers. We want to ensure the timely management of your account and help you in obtaining reimbursement from your insurance company. To accomplish this, we need your understanding and acceptance of our financial policy.
PARTICIPATING PROVIDER
We are providers for a select group of major PPO networks and the Medicare program. However, due to the complexity of managed care plans, it is difficult for us to know the details of each patient's plan. Therefore, it is your responsibility to ensure that your physician and ancillary providers are participating providers in your plan. you should verify this information by contacting your insurance plan or reviewing your provider list before making an appointment. You will be responsible for payment in full for services rendered by your physician if he/she is not a provider in your plan. We will try our best to inform you of changes in our provider status as they occur.
 
For Non-PPO plans or traditional "80/20" plans, we will file a claim as a courtesy, however, the contract with your insurance company is between you and the company. Family Medicine Center is not a party to that contract. You are ultimately responsible for your bill, regardless of any non-payment by the insurance carrier. If within 45 days, payment is not received by our insurance company, payment will be due by you, regardless of the status of your claim.
 
CO-PAYMENTS
We require your co-payment at the time of service. The co-payment specified on your card will be collected. If the co-pay amound is not listed on your card, or you have a standard "80/20" plan, we will collect 20% of the services rendered.
YOU MUST PRESENT A VALID INSURANCE CARD AT THE TIME OF SERVICE IN ORDER FOR US TO FILE A CLAIM FOR YOU.
 
DEDUCTIBLE
If you have a deductible, and it likely that the services rendered will go toward your deductible, payment in full must be mad at the time of service.
 
PRE-CERTIFICATION OF HOSPITAL ADMISSION OR SPECIAL SERVICES
Pre-certification of hospital admissions and other special services is an area we strive to help you with. With the exception of some HMO plans, it is ultimately the patient's responsibility to inform us when pre-certification is a requirement of your plan. Due to the varying policy provisions all of our patient's plans, it is impossible for us to know each patient's specific plan provisions. If you fail to disclose pre-certification requirements PRIOR to services being rendered, you will be responsible for payment of all related fees in full.
FOR OUTPATIENT AND INPATIENT SERVICES PROVIDED OUTSIDE OF OUR OFFICE, IT IS YOUR RESPONSIBILITY TO BE AWARE OF AND INFORM US OF WHICH MEDICAL FACILITIES ARE APPROVED BY YOUR PLAN, THIS INCLUDES X-RAY, LABORATORY, DIAGNOSTIC AND REHABILITATION FACILITIES.
SECONDARY INSURANCE
We will file secondary insurance as a courtesy to you. Please keep in mind that payment of your account is ultimately your responsibility, and we will look to you for payment of your account if we are unsuccessful in obtaining reimbursement by your insurance.
RESPONSIBLE PARTY (GUARANTOR)
The guarantor of the account is the patient who comes in for treatment or the adult who brings in a minor child for treatment, regardless of any court decisions or insurance coverage. If someone other than the guarantor brings a minor child in, that person will be required to pay for services rendered and they will be provided a receipt. It is not the policy of Family Medicine Centers to become involved in medical bill payment disputes resulting from divorce, etc.
LIABILITY OR AUTO ACCIDENT CLAIMS
We do not become involved in automobile or liability lawsuits, nor do we file liability claims or wait on "settlements". You will be required to pay in full of services rendered. We will provide you with the information necessary to be reimbursed.
WORKER'S COMPENSATION CLAIMS
If you have been injured on the job, we require that you provide us with all the information necessary to file a worker's compensation claim. you MUST provide the name, address, and phone number of your employer, the name, address and phone number of the worker's compensation carrier, the exact date of injury, and verification form your employer that a valid on the job injury occurred. If you are unable to provide us with this information on your FIRST visit, you will be required to pay in full at the time of service.
BILLING OF ACCOUNT BALANCES
You will receive a statement for which payment is due upon receipt. if your statement reflects an "insurance balance" your claim is still pending payment. If your statement reflects a "patient balance", this is the portion for which you are responsible. We strongly recommend your active involvement in the management of your account. When you receive your statement, compare it with your insurance explanation of benefits to ensure that the balance is correct. If payment has not been received by your insurance company, contact them. In this way, we can work together to ensure insurance companies honor their part of the agreement.
PAYMENT PLANS
We understand that from time to time unexpected circumstances may arise with make paying for medical care difficult. With this understanding, we provide payment plans to assist you in the management of yoru account. You may contact a patient account representative to arrange for this service.
NSF CHECKS
We utilize the services of ReCheck for any NSF items received. Once returned, these items are handled directly by ReCheck. When we receive 2 NSF checks on your account, we will only accept cash for future visits.
NON-PAYMENT OF ACCOUNTS
Accounts for which we are unable to collect the balance due will be referred to an outside collection agency. We also reserve the right to report this activiity to a national credit-reporting agency. Each physicians reserves the right to discontinue patient care for non-payment or non-compliance. In this instance, a sufficient prior notice will be given and records provided.

*******************************************************************************
ACCEPTANCE OF FINANCIAL POLICY
The undersigned hereby certifies that he/she has read, understood and agrees to the financial policy of Family Medicine Centers.
   
_______________________________________ ___________________________
Signature of Patient or Legal Guardian Date
 
ASSIGNMENT OF BENEFITS
The undersigned hereby requests that payment from authorized insurance carrier or state benefits program be made directly to the Family Medicine Centers physician who rendered services on their behalf for the period of: LIFETIME. The undersigned also releases the disclosure of medical information for use in obtaining reimbursement by an authorized insurance carrier.
____________________________________________________________________
Signature of Patient or Legal Guardian