1365 C-1 Westgate Ctr. Dr. Winston-Salem, NC 27103 Phone: (336) 768-6682

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Payment Policy

The following sets forth the general billing policy of .

  • I understand that it is my responsibility to provide the office of with current, accurate billing information at the time of check in and to notify the office of any changes in this information.
  • I understand that it is my reponsibility to know my specialist co-pay (which can be different than my Primary Care co-payment) and to pay-it prior to services being rendered. I understand that this is a contractual agreement that I have with my health plan and that the clinic also has a Contractual agreement with my health plan to collect co-pays at the time of servics, and they are required to report to the carrier any enrollees failing to pay the co-pay.
  • I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $35 NSF fee. I further understand that to rectify my account. I will be required to pay with cash, a money order, cashier's check, or credit card.
  • I understand that there is a $20 fee to complete disablity paperwork associated with mycare. Iwill be provided a standard form free of charge; however if additional disability forms (such as FMLA) requirencompletion, I understand that the $20 fee (payable prior to completion) is required.
  • I understand that the office will verify my insurance eligibility, deductible amounts, and coinsurance amounts prior to any elective surgery (if applicable) that I may have. I further understand that it is the policy to collect deductible and/or coinsurance prior to scheduling my elective surgery. I further understand that THE FEE l AM QUOTED IS AN ESTIMATE based on 1) anticipated surgery to be performed and 2) current information provided to clinic by my insurance carrier.
  • I understand that I will be billed for any amounts due by me (co-payments / coinsurance amounts / deductibles) and that I have a financial responsibility to pay the amounts. l understand that I will be provided with two (2) statements for any balance due after insurance payment. I further understand that if I have not made payment prior to the second statement being mailed, that the third statement will be marked as "Final Notice" and may be sent to an outside collection service if I do not fufill my financial obligations. I also understand that I will be responsible for any collection, interest or legal expenses associated with the collection efforts.
  • I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier.
  • I understand that the office has a no show fee that I will be charged if I do not give a 24 hour telephone notice to staff. No show fees are posted in the office.
  • I undersfand that if my insurance has pended or denied my claim due to reasons beyond the offices control, examples: pending or-denied pre-existing conditions, pending additional information from member, denied member covered under another health plan etc., you will be sent a final statement and the balance is due within 30 days of the notice from your Insurance carrier.

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