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    Alyson Mcguirk Job 36 Policy 3

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    api-531598416
    This document outlines the financial policies of a health care provider located at 600 N 21st St, Superior, WI. It states that payment is expected at the time of service, and that patients are responsible for knowing their insurance coverage details. It also explains that the provider will bill insurance when they are in-network, but patients will need to pay out-of-pocket for visits if the provider is out-of-network for their plan. By signing, patients acknowledge understanding their financial responsibility for any charges not covered by insurance.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Alyson Mcguirk Job 36 Policy 3

    Uploaded by

    api-531598416
    21 views1 page
    This document outlines the financial policies of a health care provider located at 600 N 21st St, Superior, WI. It states that payment is expected at the time of service, and that patients are responsible for knowing their insurance coverage details. It also explains that the provider will bill insurance when they are in-network, but patients will need to pay out-of-pocket for visits if the provider is out-of-network for their plan. By signing, patients acknowledge understanding their financial responsibility for any charges not covered by insurance.

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    alyson mcguirk job 36 policy 3

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    This document outlines the financial policies of a health care provider located at 600 N 21st St, Superior, WI. It states that payment is expected at the time of service, and that patients are responsible for knowing their insurance coverage details. It also explains that the provider will bill insurance when they are in-network, but patients will need to pay out-of-pocket for visits if the provider is out-of-network for their plan. By signing, patients acknowledge understanding their financial responsibility for any charges not covered by insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views1 page

    Alyson Mcguirk Job 36 Policy 3

    Uploaded by

    api-531598416
    This document outlines the financial policies of a health care provider located at 600 N 21st St, Superior, WI. It states that payment is expected at the time of service, and that patients are responsible for knowing their insurance coverage details. It also explains that the provider will bill insurance when they are in-network, but patients will need to pay out-of-pocket for visits if the provider is out-of-network for their plan. By signing, patients acknowledge understanding their financial responsibility for any charges not covered by insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    600 N 21st St, Superior, WI 54880 • Phone: 715-394-6677 • woodsandwater@medicalcenter.

    com

    Agreement of Financial Responsibility


    Thank you for choosing us as your health care provider. We are committed to providing quality care and
    service to all of our patients. The following is a statement of our financial policy which we require that
    you read and agree to prior to any treatment.

    Please understand that payment of your bill is considered part of your treatment. Fees are
    payable when services are rendered. We accept cash, check, credit cards, and pre-approved
    insurance for which we are a contracted provider and are the designated Primary Care Provider
    (PCP), if applicable.
    It is your responsibility to know your own insurance benefits, including whether we are a
    contracted provider with your insurance company, your covered benefits and any exclusions in
    your insurance policy, and any pre-authorization requirements of your insurance company.
    We will attempt to confirm your insurance coverage prior to your treatment. It is your
    responsibility to provide current and accurate insurance information, including any updates or
    changes in coverage. Should you fail to provide this information, you will be financially
    responsible.
    If we have a contract with your insurance company, we will bill your insurance company first,
    less any copayment(s) or deductible(s), and then bill you for any amount determined to be your
    responsibility. This process generally takes 45-60 days from the time the claim is received by the
    insurance company.
    If we do not contract with your insurance company, you will be expected to pay for all services
    rendered at the end of your visit. We will provide you with a statement that you can submit to
    your insurance company for reimbursement.
    Proof of payment and photo ID is required for all patients. We will ask to make a copy of your ID
    and insurance card for our records. Providing a copy of your insurance card does not confirm
    that your coverage is effective or that the services rendered will be covered by your insurance
    company.
    Please understand some insurance coverages have Out-of-Network benefits that have co-
    insurance charges, higher co-payments, and limited annual benefits. If you receive services that
    are part of an Out-of-Network benefit, your portion of financial responsibility may be higher
    than the In-Network rate.

    I have read the financial policies contained above, and my signature below serves as an
    acknowledgment of a clear understanding of my financial responsibility. I understand that if my
    insurance company denies coverage and/or payment for services provided to me I assume financial
    responsibility and will pay all such charges in full.

    Signature of Patient/Responsible Party Date

    Name of Patient/Responsible Party (please print) Relationship to Patient

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