 |
Ear |
|
Nose |
|
Throat |
|
Head & Neck Surgery |
|
Endoscopic Sinus Surgery |
|
|
|
| |||||||||||
|
|
|
(301) 868-8926
PAYMENT POLICY
AS A COURTESY, IF YOU PROVIDE US WITH A COPY OF YOUR VALID INSURANCE CARD, PICTURE I.D. AND REFERRAL (IF YOU HAVE AN HMO INSURANCE) WE WILL SUBMIT YOUR OFFICE VISIT TO THE INSURANCE COMPANY. PLEASE NOTE; BY PROVIDING THIS SERVICE WE ARE EXTENDING CREDIT TO YOU.
WE ACCEPT CASH, CHECK AND CREDIT CARD AS FORMS OF PAYMENT.
YOU MUST COMPLETE A REGISTRATION FORM EVERY YEAR WITH YOUR CURRENT INFORMATION AND SIGNATURES SO WE MAY BILL YOUR INSURANCE AND BE HIPPA COMPLIANT.
ALL COPAYMENTS AND BALANCES DUE ARE TO BE PAID PRIOR TO YOUR APPOINTMENT THAT DAY. USUALLY COPAYMENT AMOUNTS FOR A SPECIALIST ARE LOCATED ON YOUR INSURANCE CARD, IF NOT YOU CAN CHECK YOUR POLICY OR CALL THE INSURANCE COMPANY.
WE WILL TRY TO LET YOU KNOW IN ADVANCE IF A REFERRAL IS NEEDED FOR YOUR VISIT. ULTIMATELY, IT IS THE PATIENTS RESPONSIBILITY FOR BRINGING THE REQUIRED REFERRAL.
WHEN YOUR INSURANCE COMPANY HAS MADE FINAL PAYMENT FOR A DATE OF SERVICE YOU WILL HAVE 30 DAYS TO MAKE ANY PAYMENT DUE.
COLLECTION PROCEEDURE: IF PAYMENT IS NOT RECEIVED WITHIN 30 (THIRTY) DAYS WE WILL BEGIN THE COLLECTION PROCEEDINGS. ACCOUNTS OVER 90 (NINETY) DAYS DELINQUENT WILL BE SENT TO A COLLECTION AGENCY. WE RESERVE THE RIGHT TO APPLY APPROPRIATE LATE FEES, RETURNED CHECK FEES AND INTEREST CHARGES TO THE BALANCE DUE. IF YOU HAVE ANY QUESTIONS CONCERNING OUR POLICY, PLEASE CALL THE BILLING DEPARTMENT A 301-868-8926.
IT IS DR. GARRO’S GOAL TO PROVIDE YOU WITH THE BEST MEDICAL CARE AVILABLE. KEEPING YOUR ACCOUNT IN GOOD STANDING WILL ALLOW US TO ACHIEVE THIS.
I UNDERSTAND THAT IF MY ACCOUNT IS PLACED WITH OUTSIDE COLLECTIONS, I AGREE TO BE RESPONSIBLE FOR REASONABLE COLLECTION COSTS, WHICH MAY INCLUDE BUT ARE NOT LIMITED TO: COLLECTION FEES, COURT COSTS AND SERVICE FEES.
THERE IS A $35.00 FEE FOR
RETURNED CHECKS.
RESPONSIBLE PARTIES SIGNATURE________________________________DATE______________