Insurance Form

IMPORTANT BILLING NOTICE ♦♦♦ MUST READ AND SIGN

RE: PPO & OTHER INSURANCE BILLING

HILLTOP MEDICAL CLINIC/ HILLTOP MEDICAL CLINIC WEST offers PPO & other insurance billing as a courtesy to our patients. Our policy is as follows:

1.  We will bill your insurance, but expect payment at the time of service if your annual deductible has NOT been met.

2.  If  NO deductible or it has been met – You will be required to pay your copayment amount at the time of service.  This amount is what your insurance does not pay (i.e. some plans pay 80%, then 20% will be your copayment, others may have a straight dollar amount, $10, $20, $30, etc.)

3. We allow 60 days from the date of service for ALL insurances to respond.  Our billings are done immediately so this should be sufficient time for your insurance to respond.

4. Please understand to keep our charges reasonable,  our front office operates on a minimal staff.  Therefore, it is not feasible to do follow-ups with all insurance companies. SUGGESTION: if not payment has been acknowledged by you from your insurance company in 30-45 days, you should contact your  insurance  company and check on the processing of your claim.  This is suggested on PPO insurance as well.

5. Billing insurance does not  relieve you of your responsibility of your bill.  If insurance payments have not been received in 60 days the debt is due by you at the time whether you have PPO or Non-PPO insurance.

6. You will receive monthly statements so you will be aware of any outstanding balance on your account.  In the event that additional amounts are due from you,  we will attempt to make a courtesy phone call to you and you will be expected to pay as soon as possible.  After response from your insurance company, if termined deductible not met, payment will be required for future visits.

7. This office does not bill third party claims (motor vehicle accidents, injuries sustained shopping, homeowners liability claim, etc.)  Payment is expected at the time of service and a billing/receipt will be issued for your billing purposes.  Hilltop Medical Clinic / Hilltop Medical Clinic West will NOT bill ANY insurance for these types of services.

8. Our clinic does not allow further debt to be incurred when balance is owing.  When balance is determined  patient debt owing for you, an immediate family member or minor child you will be expected to pay balance owing to either clinic prior to being seen again.

9. Hilltop Medical Clinic / Hilltop Medical Clinic West does charge  a $20.00 fee for any returned check.

Thank you very much for your time and understanding.  If you have any questions please ask the receptionist assisting you.  I, the below signed patient (or parent, guardian, responsible party, if applicable) understand and will follow HILLTOP MEDICAL CLINIC / HILLTOP MEDICAL CLINIC WEST’S “PPO & OTHER INSURANCE BILLING POLICY”.

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SIGNATURE OF PATIENT/LEGAL GUARDIAN