Thank you for choosing us for your healthcare needs. Our goal is to provide and maintain a good physician-patient relationship. The following is our Financial Policy, which we ask you to review and sign prior to your first visit.

General Information: Your co-payment, deductible, co-insurance, or pending balance is due at the time of service. We accept cash, check, American Express, Discover, MasterCard and Visa. We can also store your preferred method of payment in your account demographics

Regarding Insurance: Our providers participate in a wide variety of insurances and managed care plans. We are happy to bill your health insurance carrier as a courtesy to you. We suggest that all patients review their health coverage with their carrier prior to receiving services or treatment. It is the responsibility of the patient to notify us of any changes regarding insurance policy. Your insurance policy is a contract between you and your insurance company and the staff will not know all the terms of your insurance policy. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare program and/or other medical insurances. The patient/financial guardian will be responsible for any remaining balances.

Self-Pay Patients: Patients without health insurance are expected to pay at the time of service. As a courtesy, we offer a 20% discount to most of the services rendered. If you are unable to pay the full balance at the time of service the remaining balance is expected upon receipt of your first statement.

Payment Arrangements: Priority Medical Group has a plan for outstanding balances owed under certain circumstances of financial hardship. We are willing to discuss your situation and try to work out a plan that will meet both your needs and the needs of the medical group. Please consult with one of our billing staff for further information.

Worker’s Compensation: We will bill your employer’s workers compensation insurance carrier and follow all other procedures as required by the state’s worker’s compensation laws. As the patient, it is your responsibility to notify us prior to the visit, that it is a work related case and to provide us with the appropriate worker’s compensation policy information.

Automobile/Other Liability Cases: Due to state laws surrounding auto insurance payments, as well as payment delays, we regret to inform you that we may not be able to bill third party administrators in liability cases. In addition, we cannot suspend our normal billing and collection process when services have been rendered. Your health insurance carrier or financial guarantor will be billed for the services.

Returned EFTs and Insufficient Funds Notice (including Credit Card Chargebacks (CCC)): There will be a $60.00 fee on all returned EFT/CCC. In the event that an EFT/CCC is returned for insufficient funds, we reserve the right to contact your bank to verify funds for any future EFT/CCC that are presented for payment on your account.

Additional Forms: Any outside forms incur an additional $35 charge that must be paid before the form can be filled out. These forms will be available for pickup 48 hours after presentation to the provider.

No Show AppointmentsUnless cancelled 24hrs. prior to scheduled appointment, your appointment will be considered a no show. Our policy allows us to charge a $75.00 fee for these types of missed appointments. Please help us serve you better by keeping your scheduled appointments. You will not be rescheduled for any future appointments until your account balance is paid in full.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

I have read and understand this financial policy. I agree to follow all financial policies stated above: