Thank you for selecting Suffolk Ob-Gyn for your medical care. We are committed to providing you with the highest quality care and achieving desired outcomes through a collaborative effort with you, the patient. Your clear understanding of our Patient Financial Policy is an essential element of you care and treatment. Please ask if you have any questions about our fees, our polices, or your responsibilities. Carefully review the following information and return this form to us with your signature and today’s date.
We request that all patients complete our Patient Information Form and sign the Patient Financial Responsibility Agreement prior to seeing the provider and annually thereafter. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc.)
It is the patient’s responsibility to provide Suffolk Ob-Gyn with accurate insurance information. We will ask for your insurance card at your first visit to obtain a copy for our records. We may occasionally request a copy at a later date to update our records so please have your insurance card every time you come to the office. If current and accurate information is not obtained at the time of service, it will become the patient’s responsibility to pay until current and accurate information is provided to the office. Not all services provided to you are always covered by your insurance. Some insurance companies arbitrarily select certain services that they will not cover. You are responsible for all services not covered by your insurance.
We participate with and accept assignment from most major insurance payers, which means covered charges, will be paid directly to us. If Suffolk OB/GYN participates with your insurance plan, we will bill your insurance plan for the fees associated with the services that you receive. If you have a secondary payer, after payment is received from the primary payer, we will automatically file a claim with them, too. After 60 days any remaining balance may become your responsibility whether or not your insurance company has made payment.
The providers at Suffolk Ob-Gyn do not all participate in every plan. It is your responsibility to ask if the provider you are seeing is a participating provider with your plan. If we do not participate in your insurance plan, you may still chose to be seen by the practice. If your plan has out-of-network benefits, your insurance plan may pay for a percentage of the fees for the services that you receive. Payment is expected in full at the time of service, however as a courtesy to you, we will file a claim with your insurance carrier on your behalf. If you do not pay in full, any remaining balance will be billed to you once we have received a remittance from your insurance carrier. If your insurance plan sends you a check to pay for services that you received at Suffolk OB/GYN, you are responsible for forwarding the check directly to Suffolk OB/GYN. If you are not sure about your plan’s out-of-network benefits, please speak with our business office at 631 473-4554.
It is Suffolk OB/GYN’s policy that co-payments, co-insurance and/or deductibles are not waived.
You are responsible for the payment of co-pays, co-insurance and/or deductibles that are required by your insurance plan. Such fees will either be collected at the time of your visit or you will receive a bill from us in the mail.
SELF PAY ACCOUNTS
Patients without insurance, patients without an insurance card on file at the time of service and patients who have not met their insurance plan deductible are expected to pay at the time of service.
We accept cash or personal checks and for your convenience, American Express, Visa, MasterCard or Discover. A fee of $30.00 will be charged for checks returned for insufficient funds. You may be placed on a “cash only” basis following any returned check.
EXTENDED PAYMENT ARRANGEMENTS
In certain cases the fees for our services may be higher than anticipated. Please let us know if the amount due is more than you are able to pay. We may be able to help by setting up a reasonable payment plan based upon your financial condition, please call our business office for assistance.
Additional fees, which are typically not covered by insurance plans, will be charged for services such as copying of medical records and completion of disability or life insurance forms. An additional monthly fee may be charged on past due accounts and co-pays not paid at time of visit. Failure to give 24-hour notice of cancellation of an appointment or not showing up for an appointment can result in a charge of $50 on your account. This charge cannot be billed to the insurance company and will be your responsibility.
PAST DUE ACCOUNTS
Balances not collected at the time of services will be billed to you on a monthly basis. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. Please be aware that if the balance remains unpaid, you and/or your immediate family members may be discharged from Suffolk Ob-Gyn. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medial care. During that 30 days period, our providers will only be able to treat you on an emergency basis.
Thank you for understanding our financial policy. If you have any questions regarding your bill or the status of your account, please call the business office at 631 473-4554.
PATIENT FINANCIAL RESPONSIBILITY AGREEMENT
I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terns may be amended from time to time by the practice.
By signing below, I acknowledge that I have read, understand and accept this Financial Policy and I agree to make payment for any co-payments, co-insurance and/or deductibles that are required by my insurance plan. Additionally, I agree to send you any checks that I receive from my insurance plan for services that I received at Suffolk OB/GYN.
I promise to pay all costs of collecting the amount I owe under this agreement including court costs and reasonable attorney fees.