FINANCIAL POLICY
☞ Insurance Verification
At each visit, the patient must provide an active insurance card with current, correct information. Without proof of insurance, the patient may be rescheduled. Scenic City Family Practice makes it a priority to verify proof of a patient’s insurance, however, it is the patient’s responsibility to know his/her benefits for all medical services including wellness benefits prior to time of service. Any balance left unpaid by insurance remains the patient’s responsibility.
☞ Insurance Processing
Please understand that payment of your bill is considered part of your services/treatment. The patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file your insurance; however, you are responsible for your co-pay or deductible which the insurance company is not liable for on the day of your visit. Insurance companies require Scenic City Family Practice to collect co-pays, deductibles or co-insurance amounts at the time of service. A deposit equal to 1/3 of costly procedures or visits is required in advance for services not covered by the patient’s insurance.
☞ Self-Pay
Scenic City Family Practice contracts with most insurance companies for patient services. The patient remains financially responsible for all his or her care, but the remaining balance for services rendered to the patient will not be billed to the patient until payment is received from the insurance company, the insurance company denies the claim, or the insurance company unreasonably fails to pay in a timely manner. A statement will be sent to the patient or responsible party. The billed amount on the statement is due when the first statement is received.
☞ Outstanding Balances
Patients will be asked to settle any outstanding balances with Scenic City Family Practice before their next appointment. You may pay any outstanding balances at any time in our office or over the phone with credit card. Patients with outstanding balances may be declined treatment or triaged for non-emergency until the balance is resolved. Patient balances which are not resolved in a timely manner will be sent to an outside collection agency. If the balance is transferred to an outside agency, the patient will be responsible for paying any additional collection fees associated with the collection of the patient balance. As of January 2015, all unpaid balances 30 days after insurance processing will incur a 19% Interest Rate. Please pay balances to avoid interest being added to your account.
Patient Accounts with outstanding balances and no payment activity will be forwarded to a collection agency at the patient’s expense. In addition to any outstanding balances, the Patient or the Patient’s representative who signs the Acknowledgement of Notice of Financial Policy agrees to pay addition collection processing fees of 30% of the original balance plus all costs associated with such collection activity, including interest incurred and reasonable attorney and court fees.
☞ 24-Hour Cancellation Policy
Scenic City Family Practice requires a 24-hours cancellation notice for all appointments as a courtesy to our staff and other patients needing medical attention. Please make sure to contact our office promptly if you need to cancel/reschedule your appointment. If we do not receive adequate notice, a $75 no-show fee will applied to your balance. THIS FEE WILL NOT BE BILLED TO YOUR INSURANCE. We understand that emergencies can occur and we will take that into account before applying any fees to your balance.
☞ Payments
Scenic City Family Practice accepts cash, checks, Visa, AMEX, MasterCard, and Discover. There is a $30.00 fee for all returned checks.
Payment can be paid in person or mailed to:
SCENIC CITY FAMILY PRACTICE
5720 Uptain Road | Building 6100, Suite 4600
Chattanooga, TN 37411-5640
☞ Patient Responsibility for Medical Service Charges
I, the undersigned, have read and understand Scenic City Family Practice’s financial policy and agree to the terms. I authorize the release of any medical information necessary to process the payment of treatment to my insurance company, and request payment of benefits to Scenic City Family Practice. I acknowledge that I am financially responsible for payment whether or not covered by insurance. I additionally agree that I will be responsible for payment in full of any co-pay at the time services are rendered as well as any deductible that may exist for said services.
I further agree that, should I be sent to collections for failure to pay for services rendered, I will be responsible for all reasonable fees and costs associated with collections, including reasonable attorney fees and court costs, and agree to pay interest on any charges sent to collections at the rate permissible by law.
PATIENT CONSENT FOR FINANCIAL COMMUNICATIONS
☞ Financial Agreement
- I acknowledge, that as a courtesy, Scenic City Family Practice may bill my insurance company for services provided to me.
- I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance.
- I understand that there is a fee for returned checks.
☞ Third Party Collection
I acknowledge that Scenic City Family Practice may utilize the services of a third party business associate or affiliated entity as an extended business office (“EBO servicer”) for medical account billing and servicing.
☞ Assignment of Benefits
I hereby assign to Scenic City Family Practice any insurance or other third-party benefits available for healthcare services provided to me. I understand Scenic City Family Practice has the right to refuse or accept assignment of such benefits. lf these benefits are not assigned to Scenic City Family Practice, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.
☞ Medicare Patient Certification and Assignment of Benefits
I certify that any information I provide, if any, in applying for payment under Title XVlll (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to Scenic City Family Practice by the Medicare or Medicaid program.
☞ Consent to Telephone Calls for Financial Communication
I agree that, in order for Scenic City Family Practice, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that Scenic City Family Practice or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or Scenic City Family Practice or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
SCENIC CITY FAMILY PRACTICE 