ALL OF THE INFORMATION BELOW MUST BE READ, COMPLETED AND SIGNEDIN ORDER FOR THE DOCTOR TO SEE YOU
Heart of the Valley Pediatric Cardiology (HOTV) requires that a guarantee of full payment be made for all service prior to being seen by enrollment in an
® plan*. * See EasyPay information and enrollment sheet.Copayments and one half any deductible are due at the time of service.
Other Important Financial Policies:
Patients with HMO's and PPO's with which we contract should only be ultimately responsible for co-payment and deductibles provided all information provided by the responsible party is accurate and any required pre-authorizations have been obtained prior to treatment. Patients with an HMO will be held
financially responsible for all charges incurred which are not pre-authorized.2)
Even though HOTV will do its best to pre-verify eligibility, it is still the responsibility of the responsible party to maintain andverify eligibility with insurance companies, regardless of whether one has public (MediCal etc) or private insurance.3)
There is a $35 charge for all returned checks.
A $100.00 fee for ALL patients will be charged for missed appointments not cancelled within (24) twenty-four hoursprior to the scheduled appointment. PLEASE NOTE: WE DO CONDUCT COURTESY CALLS PRIOR TO YOURAPPOINTMENT; HOWEVER IT IS NOT OUR RESPONSIBILITY TO REMIND YOU. We will call your home and, if available, cell phone to remind you of the upcoming appointment. ___________ Initials
Holter Monitors given out to patients must be returned within (72) seventy-two hours of receipt. Holter Monitors given out ona Friday must be returned the following Tuesday. Otherwise a $25.00 fee will be added per day late. ___________
In the event that your account must be turned over to collections, a collection fee equal to 50% of the balance will be added toyour account. Balances due beyond the date specified for the payment option chosen will be turned over to collections.7)
Visit our website or ask us for a complete explanation of our Payment Policies.
UNDERSTANDING, ASSIGNMENT AND RELEASE:
I am the Responsible Party for this patient. I have read and understand the payment policy. I authorize the release of medical information by Heart of the Valley Pediatric Cardiology to my primary care doctor, my referring doctor, toconsultants if needed and as necessary to process claims, insurance applications and prescriptions.I authorize direct payment of medical benefits to Heart of the Valley Pediatric Cardiology through my insurance companyand by participation in one of the two Payment Guarantee plans or I will pay-in-full the estimated charges for each visit atthe time of visit. I understand this assignment will stay in effect as long as the patient remains in this practice.I understand that I must submit a current and valid insurance card in order to have the insurance company billed directly. Iunderstand that if I fail to submit a valid and current insurance card or if I fail to provide a valid secondary insurance card Iwill be billed at the non-contracted rate for services payable within 15 days of my billing date. I understand that anyinsurance disputes will be settled between the insurance company and me and any unpaid balance will be due and payablewithin 15 days of the billing date.Signature: _____________________________________ Date: ________________