We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, or your financial responsibility.

PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR.

WE WILL REQUEST TO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE.

COPAYMENTS: By law we MUST collect your carrier designated co-pay at the time of service. Please be prepared to pay that co-pay at each visit.

SELF-PAY: Self-pay accounts shall exist if a patient has no insurance coverage. A payment of $100.00 is expected at time of service for new patients. Arrangements for balances over $100.00 may be worked out with the business office.

EXTENDED PAYMENT PLANS: Patients are encouraged to pay outstanding self-pay balances in full. However, payment plans may be accepted with approval of the business office.

NON-PARTICIPATING INSURANCE PLANS: As a service to our patients, we will bill as a non-assigned claim. Any outstanding balances are the responsibilities of the patients.

REFERRALS: If your plan requires a referral from your primary care physician it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU MAY BE REQUIRED TO RESCHEDULE.

ACCIDENT/WORKER'S COMP CASES: Patients shall be financially responsible for medical services related to accident/worker's comp. It is the responsibility of the patient to notify Head and Neck Surgical of: date of injury, claim #, insurance company address, phone #, and contact person.

MEDICARE: We will submit to Medicare for the Medicare allowed amount. The patient will be responsible for the deductible ($124 yearly) and 20% co-insurance, which can be billed to a secondary insurance if you have one.

RETURNED CHECK FEES: Any returned check from the bank for non-payment (insufficient funds) shall result in the patient's account being assessed a $25.00 fee per check returned.

CHILD CUSTODY CASES: Head and Neck Surgical will bill the insurance carrier for both parents; however, the parent that signs for services will be responsible for all outstanding charges and balances unless you have a court order otherwise.

WE ACCEPT CASH, MASTERCARD, VISA, AMEX, DISCOVER and CHECKS.
Thank you for taking the time to review our policies.

RESPONSIBLE PARTY SIGNATURE:_________________________________DATE:______________