FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS
FINANCIAL POLICY
At Naples Vascular Specialists LLC, we strive to deliver state of the art healthcare in a warm and personalized environment. In order for our private practice to continue to provide this level of service, patients are expected to address their financial responsibility in a timely manner. The attached policy is intended to clarify expectations with respect to financial matters.
WHAT WILL I NEED TO PROVIDE AT EVERY OFFICE VISIT?
1. Proof of insurance
2. Driver?s license
3. Social Security number (first visit only)
4. Current contact information including mailing address, phone number and email address
PAYMENT AT TIME OF SERVICE
1. For patients with health insurance, co-payment and deductibles are required at the time of service
2. For patients without health insurance, full payment is required at the time of service. 3. Overpayments will be applied to the balance or refunded upon request. Account credits over 4 years old NVS will attempt to refund using available contact information. Unsuccessful attempts to contact and refund the credit will result in the credit becoming the property of NVS.
PAYMENT TYPES ACCEPTED AND FEES
1. Credit card (Visa, Mastercard, Discover, American Express)
2. Personal check (checks returned for insufficient funds will result in a $50 fee assessed to the balance due)
BALANCE DUE AFTER HEALTH INSURANCE PAYMENTS
1. It is the responsibility of the patient to know whether Naples Vascular Specialists LLC and its providers are ?in-network? providers for their health insurance.
2. All health insurances are not the same - Naples Vascular Specialists LLC cannot know each and every service that each different health insurance will determine to be ?covered.? If a patient?s health insurance determines a service to be ?not-covered? the patient is responsible for the complete charge.
3. If health insurance fails to make payment in a timely manner to Naples Vascular Specialists LLC, balance becomes sole responsibility of patient guarantor.
4. Patient or patient guarantor will receive a Statement of Account. Payment is expected in accordance with terms reflected on the Statement of Account.
5. If payment is not received in accordance with terms reflected on the Statement of Account, the patient balance will be transferred to a collection agency for further collection process. A $50 fee will be assessed.
MISSED APPOINTMENTS/LATE CANCELLATION
1. If a patient is unable to meet a scheduled appointment time, please kindly inform the office at least 24 hours in advance so we will utilize the time to see other patients.
2. If a patient misses their appointment and does not cancel/reschedule at least 24 hours in advance, Naples Vascular Specialists LLC will charge the patient a $50 fee which must be paid prior to being rescheduled.
3. How may we contact you for appointment reminders: Please see field below.
DISMISSAL OF PATIENTS FROM PRACTICE
1. If a patient has a delinquent/collections balance, Naples Vascular Specialists LLC may dismiss the patient from the practice. The patient will be notified of dismissal via USPS correspondence and provided 30 days to find alternative care. During that 30 day period, only emergency medical care will be provided by Naples Vascular Specialists LLC.
Please type patient first and last name
Please type Phone Number or Email Address
Please type date agreed to terms
Please type your name to agree to the terms
