FINANCIAL POLICY
We would like to welcome you to the office of Dr. Stephen Rodrigues. Our goal is to provide you with the very best possible care available. In order to meet this goal, we need your assistance and understanding of our patient policies. Our Policy is a necessary part of assuring the financial resources needed to maintain this health care facility for our patients.
Insurances companies
We are here to help answer questions you may have regarding your insurance coverage and payments. However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to your contact unless we are a contracted provider with you plan. Insurance payments are based on a Usual and Customary Rate (UCR) by most companies. Our fees fall within the UCR range; unfortunately, some insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. Unless we participants with your insurance plan, you will be responsible for our charges regardless of the company’s arbitrary determination of the UCR. If we are contracted with your insurance plan, we will file your claims directly with your company. If we are not, we will supply you with and extra copy of your office visit to send to them. This is a complete form for them to process your charges. Note: The Office of the Inspector General strictly prohibits the waiving of co-pays or deductibles. It is considered fraudulent to accept “insurance only”.
Office visits
Any required co-payment or deductible amounts will be collected at the time of the visit. If Dr Rodrigues is not contracted with your insurance plan, payment for services rendered is due at the time of your visit.
A $50.00 fee will be charged for missed appointments and for last minute cancellations. This fee must be paid before making another appointment. We accept cash, checks, debit cards, Visa/MasterCard, Discover, and American Express.
Unpaid Balances
Balances that are 90 days past due will begin incurring interest charges at an annual percentage rate (APR) of 15%.
Fee for Business Correspondence and Forms
The fees for completion/preparation of the following forms/correspondence may not be covered under your insurance plan: School physicals, sports physicals, camp registration, disability, FMLA, LOA; written correspondence to employers, schools and insurance companies; reissuing previously written prescriptions or any prescription request without an office visit. Completion of these documents require a fee of $25.00 which is payable in advance.
Thank you for choosing Dr. Rodridgues as your Family Physician/Pain Therapy doctor. We believe it is important that the doctor’s patients fully understand our financial policy so that Dr. Rodrigues can concentrate on you and your medical needs. It is your responsibility to notify us in writing of any changes in your account status (i.e. address, phone number, insurance). Our business office is available during office hours. Please call with any questions you may have regarding our policies.
I have read the above and I understand and agree to this financial policy.
____________________________________ __________________________________ ___________
Signature of Patient Print Name Date
