Camelback Spine Care believes that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy.
1.PAYMENT- is expected at the time of your visit. (This includes Copayments, Deductibles, Coinsurance, Missed Appointments, Procedure Prepayment; unpaid balance after insurance has paid their portion, Past Due, etc.). If you are unable to make a full payment Camelback Spine Care reserve the right to reschedule your appointment for a later time when you are able to make your full payment, (any payment due or owed at time of service). If a prepayment is made for any services and a refund is due after insurance processes, any outstanding balance on your account will be deducted before issuing your refund. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit. We do ask for a copy of an ID card or license and insurance cards.
2.INSURANCE- We are participating providers with several insurance plans. We will file all of these insurance claims. A list of these insurance plans is available upon request. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you will be billed. If we later receive payment for your insurer, we will refund any overpayment to you.
If our providers are not listed in your plan's network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim in for you on an unassigned basis. This means the insurer may send the payment directly to you and therefore, our charges for you are due at the time of service. Due to the many different insurance products out there, our staff cannot guarantee your eligibility and coverage. Be sure to check with your insurer's member benefits department about services and physicians before your appointment. Many web sites have erroneous information and are not a guarantee of coverage. You are responsible for obtaining a properly dated referral, prior authorization if required by your insurer and responsible for payment if your claim is rejects for the lack of one.
Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered", you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. All procedures billed in this office are considered covered unless limited by your specific insurance policy.
Camelback Spine Care only has a specific amount of time to submit a claim to your insurance carrier. If your coverage/insurance company changes and we bill your old carrier we may miss the time limit to process the claim. In this case, the claim becomes your responsibility for payment, so please notify us immediately if your coverage changes so that we can accurately submit the claims.
3.COLLECTION- If you have an outstanding balance over 120 days old and have failed to make payment arrangements (or become delinquent on an existing payment plan), we may turn your balance over to a collection agency and/or an attorney, which may result in reporting to credit bureaus and/or legal action. Camelback Spine Care reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You agree to pay Camelback Spine Care for any expenses we incur to collect on your account, including attorney fees, collection fees, and contingent fees to collection agencies that can be more than 35% of the delinquent balance. Contingency fees will be added and assigned to the collection agency immediately upon our referral of your account to the collection agency of our choice. You agree that in order for us to service your account or to collect any amounts you may owe, we may contact you by phone at any number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded voice messages and/or use of an automatic dialing device.
4.RETURNED CHECKS- will incur a $40.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $40 service charge to pay the balance prior to receiving services from our staff or the physician. Stop payments or overturned chargebacks on your credit card constitute a breach of payment and are subject to the $40 service fee and collections action. All bad checks written to this office are subject to collections and will be prosecuted in Maricopa County.
5.ACCOUNTING PRINCIPALS- Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding dates of service.
6.FORMS AND CONSULTS FEES-Completing insurance forms, copying medical records, etc... requires office staff time and time away from patient care for our doctors. We require pre-payment for completing forms, copying medical records, notarizing, or for extra written communication by the provider. The charge is determined by the complexity of the form, letter, or communication. On occasion, our staff may be asked to provide a deposition and/or other testimony or actions concerning your care. There is a separate fee schedule for such activity. The fees for such activity are to be paid by the patient regardless of the party requesting the activity.
7.CANCELLATIONS OR MISSED APPOINTMENTS- If you do not cancel your appointment at least 24 hours before, or if you no-show, we may assess you a $35.00 missed appointment fee. If you do not cancel your procedure with at least 24 hours' notice, you may be assessed a $500.00 missed procedure fee. Multiple missed visits may result in discharge from the practice.
8.RESPONSIBILITY FOR PAYMENT- I understand that I, personally, am financially responsible to Camelback Spine Care for charges not covered by the assignment of insurance benefits.
9.ASSIGNMENT OF INSURANCE BENEFITS- I hereby assign, transfer, and set over directly to Camelback Spine Care sufficient monies and/or benefits for basic and major medical to which I may be entitled for professional and medical care, to cover the costs of the care and treatment rendered to myself or my dependent in said practice. I authorize Camelback Spine Care to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to Camelback Spine Care. I authorize Camelback Spine Care to release all medical information requested by my health insurance carrier, Medicare, other physicians or providers, and any other third-party payers.
10.RELEASE OF INFORMATION- I hereby authorize the and direct Camelback Spine Care to release to governmental agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment.
I have read and understand the practice's financial policy of Camelback Spine Care and I agree to be bound by its terms. I understand that I am financially responsible for ALL services I receive from Camelback Spine Care. I hereby assign all medical and surgical benefits and authorize my insurance carrier
(s) to issue payment directly to Camelback Spine Care. This financial policy is binding upon you, your estate, executors and/or administrators, if applicable.
I also understand and agree that such terms may be amended by the practice from time to time.