Hospital Affiliation
Financial Policy
We appreciate payment at the time of service and will accept personal checks, VISA, MasterCard, American Express, and Discover. Prompt payment helps keep both our costs and fees down. After your medical care is completed, you will receive a yellow (encounter) form and be directed to our Cashier. There you will receive a receipt for your payment or insurance co-pay and any insurance forms that you may need.
Our Physicians share your concern about the cost of medical care. We strongly believe that the best medical service is based on a friendly, mutual understanding between doctor and patient. We therefore invite you to discuss frankly with us any questions you may have regarding our services or fees. If you anticipate problems with your insurance coverage or personal payment, you are encouraged to contact our financial counselor. The earlier we know about a possible problem, the better we are able to develop suitable options for you.
This is an agreement between Georgetown Medical Clinic, as provider and creditor, and the Patient. By executing this agreement, you, the Patient, are agreeing to pay for all services that are received.
Payment
Monthly Statement
If you have a balance on your account, we will send you a monthly statement. All balances are to be paid in full upon receipt of this statement. Payments not received within 15 business days of receipt of statement are considered past due and could be subject to late fees or interest penalties.
Payment options if you have no insurance
A. An advance deposit of $130 is required prior to your first visit. The deposit will be more if your first visit is for an annual and the cost depends on the age of the patient. You may pay by cash, check, or credit card. Any remaining balance will either be refunded or credited towards future services according to your wishes.
B. For extensive services such as deliveries, you may prefer to secure a loan from your financial institution or credit union. This can be discussed with our Financial Department.
Payment options if you have insurance:
A. You must pay all deductibles, co-pays, and co-insurances in full at the time of service. You may choose to pay with cash, check, or credit card.
B. You may choose to pay for all services in full and file with your insurance company
Insurance
Insurance is a contract between you and your insurance company. We are not a party to this contract in some cases. We will bill your primary insurance as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If the insurance does not pay within 60 days from the time services are rendered, the balance may be billed to you.
Required Payments
Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these fees. If you fail to bring your copay with you to your visit, a $10.00 processing/billing fee will be added to your account.
Discounts
Patients not covered by insurance are eligible for a discount if payment is made in full at time of service only.
Returned checks
There is a fee of $25.00 for checks returned by the bank. If a returned check is received on your account, you will be required to pay all fees associated with this check and all future visits in cash prior to being seen.
Missed appointment fee
When a patient does not show for an appointment, or cancels with less than 24 hours notice, a $35.00 fee will be charged. When a patient does not show for an extended appointment, such as a physical or annual exam, or cancels with less than 24 hours notice, an $80.00 fee will be charged. This fee must be paid prior to scheduling a new appointment. Patients with multiple missed appointments may be asked to transfer their records to another practice.
Past due accounts
If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your unpaid balance to a collection agency and you do not pay the collection agency this will be reported to your credit file.
Divorce
In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.
Account summaries
If you require an account summary for the most recent calendar year for flex plans, income tax, court purposes, etc., you will be required to pay a $5.00 fee for each account that you request this on.
Workers Compensation
As of 1/1/03 we no longer perform services under workers compensation. If you fail to state that your visit is for a job related injury, you will be financially responsible for all charges incurred for that visit.
Personal Injury/Motor Vehicle Accident - MVA
We do not accept personal injury cases nor do we bill attorneys for medical services. Any services performed in relation to a personal injury case must be paid in full at time of service.
Blue Cross Blue Shield and Humana are the only insurances that we file MVA related offices visits. If you do not have either of these insurances, payment is due and payable by you at the time of service. A billing summary will be provided to you for your auto insurance claim.
Disputes
Any disputes of your account should be done in writing within 30 days of the receipt of your statement. Your dispute will be addressed immediately and you will be notified of the outcome within 30 days of the receipt of your dispute.
Additional Services
Please be aware that there are fees for additional services such as prescription rewrites, triplicate prescription management, copying medical records, depositions, and special forms. Please check with the Financial Department for specific fees for these additional services.
Sports Physicals: There is a $35 fee for sports, college or camp physicals. This is not a covered benefits by most medical insurance plans.