At Doylestown Thyroid and Endocrine Associates, we believe that all patients who are rendered care at this office deserve the best medical care that can be provided. In order for us to provide you with the highest quality medical care and current technology, we must insure that we are able to meet the expenses necessary to operate this facility. To ensure that these expenses are met, we provide you with this Agreement regarding our financial policy and your agreement to pay for services rovided.

    Your insurance policy is a contract between you and your insurance company. We do provide your insurance carrier with information regarding your diagnosis and treatment. We do not get involved in matters between you and your insurer such as disputes regarding deductibles, copayments, non-covered charges and “usual and customary” charges. If your insurance carrier does not provide payment within 60 days after treatment, you will be responsible for payment. You are responsible for timely payment on your account. Doylestown Thyroid and Endocrine Associates is required in accordance with its contract with your insurer to collect your copayments at the time of service. We will require that you pay any amount not covered by your insurance, such as un-met deductibles and copayments under your policy on the day of service. Our policy is to collect it prior to seeing the doctor. If you are unable to pay your copayment at check-in, another appointment may be made for you. Any additional payment owed will be collected in full at the time of service. If needed, we are happy to work with you to arrange a payment plan.

    It is your responsibility to provide us with your current insurance card and photo identification at every visit so that we may bill the correct insurance company in a timely fashion. It will be reviewed or copied every time you are here for a visit, no matter how frequently you are seen. If a claim is rejected because your insurance does not cover the type of service rendered, you will be held responsible for the outstanding balance. Please call the telephone number on your insurance card before your appointment and they will assist you in finding out whether the service to be provided at the appointment is covered, what your copay is and what your deductible is. Please educate yourself as to your coverage so that office visits, procedures, testing, and specialist referrals may be arranged to best suit your needs. If your insurance does not cover the cost of your visit or procedure, you will be responsible for the charges for all services rendered.

    Once we determine your personal financial obligation or after your insurance company reimburses Doylestown Thyroid and Endocrine Associates for a portion of your care, we will mail you a statement. Payment is expected upon receipt of the statement. Any account past due by 90 days or more may be subject to submission to our collection agency. If your account becomes delinquent and is placed into our collection process, collection fees will be your responsibility and added to your balance. Doylestown Thyroid and Endocrine Associates reserves the right to discharge any patient at this point. By signing our financial policy, you agree to pay these added fees, along with any and all costs associated with the collection of your account, including interest charges and attorney fees.

    If a new problem is encountered or if changes in treatment of a pre-existing condition are discussed in the process of performing a visit or exam, an additional copay and deductible payment may be incurred.

    If you are seen in our office by a nurse or a medical assistant for minor medical services, you may be charged a limited office visit and applicable co-pays will be collected.

    If you carry a balance on your account during the time you present at our office, a payment on your account will be required at the time of service. Doylestown Thyroid and Endocrine Associates reserves the right to terminate any patient who misses a payment. Under unusual circumstances, we are willing to work out personalized payment schedules if you so require and can demonstrate need. We accept cash, check or credit card.

    Patients are required to pay the estimated self-pay portion of elective/non-covered procedures at the time services are being rendered based on insurance verification and eligibility of benefits.

    We will submit your insurance claims. However, it is important to remember that your insurance is a contract between you and your insurer. Although we file insurance claims as a courtesy to you, you are still responsible for payment of services regardless of the amount your insurance pays.

    Our office accepts most credit and debit cards. Our office also accepts valid check or cash. There will be a $20 fee for all returned checks. Once we have a returned check for you, we may require that all future payments be with cash, money order, cashier’s check or credit card.

    If you wish to pay cash, you will always be provided with a receipt so that you will have a record of your payment. Please make us aware if you are not provided a receipt.

    If you have Medicare as your primary insurance carrier but you do not have a secondary insurance, you are responsible for the deductible and coinsurance. If Medicaid is your secondary insurance, we do not participate with that program and therefore you would be responsible for deductibles and coinsurance as well. You are also responsible to pay for services not covered by your Medicare insurance unless you have a secondary insurance. You will be required to sign an Advanced Beneficiary Notice for noncovered services or services thought to possibly not be covered.

    If you have an insurance plan that we do not participate with, you may have out-of-network benefits. These benefits typically have a higher copay, coinsurance and/or deductible out of pocket costs. You will be considered a self-pay/ uninsured patient if you do NOT have out of network benefits.

    Patients have the option to pay out of pocket for services. Payment in full is expected at the time of service.

    We understand that you may not be able to keep all of your scheduled appointments or might occasionally be late. Please understand that missed appointments have a detrimental impact on our practice and other patients. They also affect our ability to serve other patients in need of medical care. We understand there are circumstances that may require you to cancel your appointment. If you must cancel or reschedule your appointment, please do so at least 24 hours in advance. Failure to cancel or reschedule an appointment at least 24 hours in advance will be considered a No Show. We reserve the right to charge you $50 for any No Show. Payment of the Missed Appointment fee will be required prior to scheduling another appointment. Doylestown Thyroid and Endocrine Associates reserves the right to discharge any patient with more than two No Show appointments upon 30 days written notice to the patient to seek medical help from another practice.

    If your insurance carrier requires a referral or authorization for your visit, it is your responsibility to make sure that our office receives current valid authorization. If you do not have a valid referral or authorization at the time of service, we may be unable to treat you until one is obtained. You may sign a waiver agreeing to treatment without the referral however full payment will be expected should the referral not be received. Please remember that it is your responsibility to make sure we are on your plan’s provider listing. We appreciate your understanding of the ever-changing requirements of managed care plans and our position to adhere to their policies or requirements.

    Due to the increasing costs of providing our patients with the highest standards of care, we must impose a charge for certain records and forms. It takes time for our providers and staff to retrieve and copy files, complete forms and write letters. The charge for completing forms is $25. Additional charges may apply for the following types of forms or documents: FMLA, Disability, School forms not completed during an appointment and Supplemental Insurance forms, dictated letters or extensive forms with review of medical records. Copies of records for personal use will be charged the allowed fee by the Commonwealth of Pennsylvania which changes annually.

    I hereby authorize Doylestown Thyroid & Endocrine Associates to release any information necessary to insurance carriers to process claims. I authorize my insurance benefits be paid directly to Doylestown Thyroid & Endocrine Associates, LLC. I understand that I am financially responsible for any balance remaining after submission to my insurance. I have received and reviewed the practice’s Financial Policy and Procedures.

    Name of Patient or Responsible Party*:
    Signature of Patient or Responsible Party*: