FINANCIAL POLICY

v     Co-pays must be paid at the time services are rendered, as required by your insurance company.  We accept cash, check, Visa and MasterCard.  A $5.00 billing charge will be added to all co-pays not made the day you are treated.  Also, there will be a $20.00 fee for all returned checks.

v     If your insurance company requires you to have a referral from your primary care physician in order to be treated by our doctors, please verify that this process has taken place.  If a referral is not in place, you cannot be seen until one is received.

v     If you do not have insurance (self-pay), payment in full is expected at the time of service. Please be prepared to pay $100 for a New Patient visit or $50 for an Established Visit upon arrival.  The balance for your office visit and/or procedure will be collected at check out. The balance owed will be determined by the level of service provided that day.  

v     In case of divorce, the parent seeking treatment must supply the responsible parent’s billing and insurance information.  We may also need to ask for a copy of the divorce decree as to determine who is responsible for the bill especially if it is not the parent bringing in the patient.

v     Accounts that are 90 days past due, could be subject to collection action.  Any legal activity would cause a breach in the physician/patient relationship, resulting in discharge from the practice.  There will be a 25% administrative fee charged to your account, payable by you if your account is sent to a collection agency for payment.

v     A parent or legal guardian must accompany patients who are minors (under 18 years old) on the patient’s first visit.  Future appointments must be accompanied by an adult but does not have to be the legal guardian.

v     Being a surgical office, we realize that disability and Family Leave Act forms will need to be completed by our office, we are happy to do them.  There will be a charge per form based on the length of the form. Copies of your medical record are available, there will be a fee charged that is determined by how many pages you are requesting.

I have read, understand, and agree to the above Financial Policy.  I understand that charges not covered by my insurance company, as well as applicable co-payments and deductibles, are my responsibility.

I authorize my insurance benefits be paid directly to Toledo ENT, Inc.

I authorize Toledo ENT, Inc. to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.

Printed Name                                                                                                   Date

Signature of Patient /Responsible Party                                                            REV: 08/29/05