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We are committed to providing you with the best possible care, and we 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, financial policy or your responsibility.
UNINSURED PATIENTS
Payment in full is due at the time of service for all office visits and/or procedures, unless other arrangements are made in advance. We accept cash, checks, VISA and MasterCard.
INSURANCE**
It is your responsibility to know your insurance plan and to verify coverage for referrals to other doctors, recommended tests and laboratories. We make every effort to refer you to providers, labs, and x-ray facilities that are members of most health plans. However, there are more than 100 plans for which we are providers, and it is not possible for us to know the details for each of these plans. If you are in doubt as to whether a procedure, lab test or x-ray is covered, or if you are unsure as to where it must be performed. Please call your plan's member services department and check. This office cannot be responsible for out-of-pocket expenses incurred from utilizing the wrong provider, facility, or for undergoing non-covered tests or procedures.
PPO Insurance
We will bill your insurance company. Co-payment and any anticipated deductible are due at the time of your visit.
HMO Insurance
The only HMO we are contracted with is Greater Newport Physicians. You must bring a copy of your current card. Infertility
visits must have prior authorization from your PCP. Your co-pay will be collected for each office visit.
Surgery Charges
We will bill your insurance. Anticipated deductible and co-payments must be paid prior to the scheduled surgery.
LAB TESTS AND OTHER CHARGES
If your visit includes lab tests, x-rays, biopsies, pap smears or cultures, you will receive separate billing from the company performing the processing and evaluation of those tests. It may take as long as 2-3 weeks to receive your results. If you do not hear from the office after three weeks, please call to check for results. You will always be notified directly of any abnormal results.
MINORS
The parents (or guardians) of a minor are responsible for full payment.
**Insurance is a contract between you and your insurance company. We are a party to this contract in some cases. If we
are a party to your insurance contract, we will handle claims according to our agreements with the insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, usual and customary charges, etc., other than to supply information as necessary. You are ultimately responsible for the
timely payment of your account.
I have read and understand the above information.
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Responsible Party's Name - (Parent or guardian of patient under age 18)
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It is our hope that the above financial policy will assist us in providing quality care to our patients. If you have any questions or need clarification of any of the above policies, please do not hesitate to speak with someone in our office. Instructions:
1. Print this form, then fax or mail it.
2. Fax: (919) 781-9247
3. Mail Address:
North Raleigh
11001 Durant Road,
Ste. 100
Raleigh, NC 27614
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