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Financial Policy Acknowledgement

Fees and Payments:

Fees are standard and based on the type of your visit. Payment in full is required at the time of your visit and can be made with cash, personal check, money order, or credit card.

Insurance co-payments and/or deductibles (if applicable) are due at the time of service. We will not bill your secondary insurance for co-payments and/or deductibles. If you are unable to pay your co-payment at your visit, your appointment may need to be rescheduled.

While filing insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. Your insurance is a contract between you and your insurance company, and we are not party to that contract. Before your visit, contact your insurance company to verify that we are participants in your plan, and the services you intend to receive are covered. In order for us to file a claim, you must present your CURRENT insurance card at each visit and communicate any changes in your personal information.

Not all services are a covered benefit in all policies, so it is very important that you understand the provisions of your individual policy. Insurance companies select certain services they will not cover; therefore we can’t guarantee payment of all claims by your insurance company. Full or partial denial of your claim does not relieve you of your financial responsibility.


PLEASE NOTE: Each visit is documented in your medical record and a diagnosis is made by the provider. Diagnoses are made based on medical information, not based on coverage by Insurance Companies. To request a diagnosis change solely for the purpose of securing
reimbursement from an insurance carrier is inappropriate and is considered insurance fraud.
Care Resource will verify your insurance coverage prior to each visit. If we are unable to verify active coverage, you will be advised and offered the option to reschedule your appointment or at your discretion, you may elect to pay for the services you receive yourself.

Self-Pay:

In order to address the needs of our patients without insurance and patients with coverage limitations, we offer a Sliding Fee Scale Discount Program (SFSD) based on patient income and family size to. In order to qualify, patients/guarantors need to submit proof of income
according to program guidelines. Please ask any staff member to receive more information about enrollment in our SFSD Program.

Medicare and Medicaid:

We gladly accept Medicare patients and will bill our services at the allowed rate. Medicare regulations require that you sign an Advanced Beneficiary Notice (ABN) for services that Medicare may deem not reasonably necessary. The ABN form helps to explain which services Medicare may not cover and may be your responsibility. Medicaid patients must present their card at each visit.

IT IS YOUR RESPONSIBILITY TO PROVIDE YOUR CURRENT INFORMATION AT EACH VISIT.

Miscellaneous Charges:

Non-Sufficient Funds (NSF) checks – are subject to a $25.00 fee (in addition to fees from your bank).

Lab Charges – Depending on your insurance, you may get a separate bill from the lab facility that performs your lab work. These charges should be discussed directly with the Lab facility.

Refunds – Patient Refunds are processed on the last Wednesday of the month. Any account that has outstanding claims will not be eligible for a refund.

Records Requests – $1 per page for the first 25 pages, and .25 for each additional page. Health Records sent directly to a Primary Medical Provider and/or Specialists will be of no charge.

See our full list of health services by clicking on the link below or call 305-576-1234:

> Health Services

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