WE MAY DECIDE TO USER SOFTER LANGUAGE AS THE FOLLOWING WILL ALSO BE IN A FORM THAT PATIENTS NEED TO DOWNLOAD AND SIGN.
Thank you for choosing ThorntonMD as your Healthcare Provider. Please help us continue to provide the quality of service you expect by reviewing and signing the following financial policy. Please direct any questions or concerns to the ThorntonMD Staff.
Full payment is required at the time of service unless prior arrangements have been made as outlined below:
We accept cash, checks and credit cards including Visa, Master Card, Discover and American Express.
Patients under the age of 18
Any patient under the age of 18 must be accompanied by a parent or guardian who will be responsible for payment at the time of service. This office is not bound by any divorce decree or other family relationship contracts.
Your insurance policy is a contract between you and your carrier and we are not a party to that contract. Your bill with the physician is your responsibility regardless of insurance payment. It is the responsibility of the patient to provide this office with current information. This office will file all claims as a courtesy to our patients and you may be responsible for any deductible or any other non-covered amounts. If your insurance payment is not received within 90 (ninety) days, the balance will automatically be assumed to be due from you.
UCR (Usual & Customary Reimbursement)
Considerable care has been taken in setting our fees. We want to assure you that our charges accurately reflect the complexity of care rendered and the skill and expertise required for your care. We assure you that our fees reflect what is usual and customary for our geographical area. If your insurance company’s fee schedule falls below the level of our charge, you will be responsible for payment in full (unless we have a written contract with your insurance company).
Managed Care Contracts (if applicable)
We currently participate in some “Managed Care” insurance programs. If you are covered by one of these identified programs, you will be required to pay any co-pay, deductible or non-covered services at the time of service. It is your responsibility to present your current insurance plan ID card.
We participate with Medicare. This means that you will be responsible for 20% of the approved Medicare fee, the yearly deductible and full payment of any non-covered services. There may be occasions when you will be asked to sign a waiver for any non-covered services that may not be covered under these plans.
Litigation Cases (auto accident or any liability injury)
You are responsible for all fees incurred.
We require pre-authorization from your employer. This practice will file your claim to the appropriate carrier. However, if the worker’s compensation claim is later disputed, you will be responsible for payment in full.
In accordance with Federal Laws and internal policies, this office will be unable to provide “Professional Courtesy”.
If your account becomes delinquent, and sent to any outside agency or attorney for collection, you will be responsible for all costs, including agency fees, attorney fees, court costs and any other related expenses. This practice reserves the right to discontinue the physician/patient relationship.
A fee of $20.00 may be charged for each check returned to us.
Completion of Forms:
A fee of $25.00 may be charged per set of forms needing completion for your employer, disability or other.
Duplication of Medical Records
A duplication fee may be charged up to an amount allowed by state law.