Information For The Patient

1. Patients who carry standard health insurance should remember that professional services are rendered and charged to the patient and not to the insurance company. All patients with standard health care insurance are expected to make payment as services are rendered, regardless of pending insurance, litigation, etc.
2. Patients with contact health plans should present their insurance ID card to the receptionist after completing this form. Some contact health plans (HMOs, PPOs, IPAs, etc) require a copayment as the time of services. Most contract health plans require that the claim be submitted to our office.

Office Financial Policy

• Payment Responsibility – Patient and/or Guarantor assumes responsibility for all charges resulting from treatment provided by Shadi A. Qasqas, M.D. and his staff. As a courtesy service for our patients, we will bill most insurance carriers in expectation of prompt payment. However, responsibility for unpaid balances is that of the patient and/or guarantor. Payment for service is due within 30 days of the billing, unless financial arrangements are made in advance. We accept cash and credit cards only; We do not accept checks.
  It is the responsibility of the patient and/or guarantor to understand the terms and conditions of their insurance plan. Insurance providers do not always cover preventative or well care visits. Contact your carrier’s Member Services Department for clarification. We insurance information is unavailable or invalid information is provided at the time of service, the patient and/or guarantor may be held responsible for charges incurred.
• Initial visits – Patient and/or Guarantor are required to pay estimates charges related to their first appointment at time of service. Individuals excluded from this are contracted HMO/PPO enrollees with current eligibility, Medicaid enrollees, and Medicare subscribers.
• Appointment Requirements – For each visit, Patient and/or Guarantor are required to bring Photo ID, the patient’s current insurance identification card(s), and applicable copayment. They must also advise the clinic of and change in insurance coverage and communicate change in name , address, telephone numbers, and employer. Missed appointments without a 24-hour prior notification are subject to a $25 fee. This fee is not covered by your insurance and thus will be billed to the patient directly.
• Forms – Due to the considerable time involved in the completion of forms, our practice will charge a $15 form fee. This fee will be billed tot he patient directly and is not covered by your insurance company. Payment is sue at time of pick up. Please allow 15 working days to complete all forms.
• Medical Records – Request for medical records will require a fee of $15 with a $0.25 per page copied. This fee will be billed to patient directly and is not covered by your insurance company. Payment is due at prior to records being released. Requests will be processed within 10 working days, inless in the even or an emergency, records will be provided as soon as possible. Records will have to be picked up by the patient or authorized party.
• Cash Patients –
All services are rendered on a cash basis and must be paid in full at the time of service.
• HMP/PPO,HAS Plans – Co-payment is due at time of each visit. HMO/PPO enrollees may not receive regularly monthly statements unless there is a balance due. Failure to pay the co-payment at time of visit may result in a billing fee. HAS Members may be required to pay a portion at time of service is deductible is unmet.
• Employer Sponsored Health Insurance – Shadi A. Qasqas, M.D. will bill most employer sponsored insurance carriers as a courtesy service for our patients. Secondary insurance carriers, when contracted with Shadi A. Qasqas, M.D. may also be billed as a service for our patients when secondary insurance information is presented at the time of service.
• Medicare – We must have a copy of your Medicare card and any Secondary insurance you may have. We do not accept assignment of Medicare claims, which means, you will be responsible only for your deductible and 30% of allowed charges. There are certail procedures and supplies which are Non-Covered services for Medicare patients. If you need such services, you will be informed tha thtey are not covered and if you still wish to receive such services in this office they will be on a cash basis at the time of service.
  Amounts which are over 60 days past due be an insurance company are immediately due from the patient. Amounts over 90 days past due are subject to collection procedures, which could include small claims court, or a 1.5% service charge per month on the unpaid balance.

Authorization

To:

Advanced Health Care Directive