We feel strongly that all patients deserve the best medical care that we can provide. Further, we feel that everyone benefits when definitive financial arrangements are agreed upon. Accordingly, we have prepared this material to acquaint you with our financial policy.
Our professional services are rendered to you, not your insurance company; therefore, payment for treatment is your responsibility. If you are covered by a plan (PMD, United Health Care, HealthChoice, HMO/PPO plans, etc), your co-payment, deductible and non-covered charges are expected at the time of service along with any past due balance. Please notify us of any change in your insurance, address, place of employment, phone number, etc when you arrive and before you see your physician or have any testing. Failure to notify us of these changes will result in you being responsible for the bill. It is your responsibility to know and understand your insurance.
You may use your Master Card, Visa, Discover, or debit card to charge current services or any outstanding balance on your account.
All patients must acknowledge acceptance of the following information when they first see the physician. It is important that patients read and understand the billing procedures of the clinic as they can only help our patients to be informed about services through our clinic and what patients should expect from their insurance company.
- I authorize this office to release or receive any information necessary to expedite insurance claims.
- I hereby authorize this office to bill my insurance company directly for their services.
- If I am not covered by medical insurance I understand full payment is due at the time of each visit and/or service.
- I authorize payment directly to this clinic of any insurance benefits otherwise payable to me.
- In the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to Cullman Internal Medicine for which these fees are payable.
- I understand certain routine services are deemed necessary by my physician for the maintenance of good health and may not be covered or deemed medically necessary by my insurance carrier and that I will be expected to pay for these services in full at the time of service, or when billed, if they are denied or not paid by my insurance carrier for any reason.
- If I need an insurance referral to see a specialist I will need to request it at least seventy two (72) hours before each appointment with my specialist, so I will be covered.
- I understand that I am directly and fully responsible to this clinic for charges not covered by my insurance. I further understand that such payment is not contingent on any settlement, judgment or insurance payment by which I eventually recover said fee.
I realize that if my insurance company fails to pay my balance in full, or there is no payment within 60 days, it is my responsibility to pay any and all charges incurred by me at Cullman Internal Medicine.
I further understand and agree, that if I fail to make timely payments on my account, I will be responsible for any and all costs of collection, including filing fees collection charges and fees as well as but not limited to all attorney's fees and waiver all claims of exemption under the law of the state of Alabama.
I understand there will be a $30 charge on all returned checks. Returned check amount and fee will need to be paid by cash or credit card.
I understand that I may be billed $25 for appointments not cancelled or rescheduled within a 24 hour notice; constant rescheduling or cancellations could result in termination from our practice due to non-compliance of physician instructions.
Please present all medical insurance cards and a photo ID so we may make copies for our records. We are sensitive to identity theft and must assure that our care is given to the proper patient. We make every effort to assure your identity matches.