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

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Family Care offers you complete family care services.

Helping you stay healthy.

Payment is due at the time services are rendered.   Patients are responsible for providing (the office) with current, accurate billing information at the time of check in and to notify the office of any changes in this information.   Patients are further responsible for knowing the co-pay of specialists, which may be different from co-payments due our office.   Contractual agreements are between patients and their health plan.   The office also has a contractual agreement with that health plan to collect co-pays at the time of service, and they are required to report to the carrier any enrollees’ failing to pay the co-pay.

A charge of $35 will be charged for insufficient funds checks (NSF checks) on a per check basis.   Future charges for accounts with NSF charges will require payment with cash, money order, or credit card.

A $20 fee will be required to complete disability paperwork associated with your care.  In some circumstances, an office visit may be required in addition to the form fee to complete the form.   If additional disability forms (such as FMLA) require completion, it is understood that the $20 fee (payable before completion) is required.

Fees for other types of paper work (e.g. physical forms required by work, driver’s license forms, letters to attorneys, etc.) will be charged.   These fees will vary according to the complexity of the paper work.

Insurance eligibility, deductible amounts, and coinsurance will be verified by the office prior to elective procedures such as minor surgery performed in the office.   These include elective removal of skin lesions, laceration closure, etc.   Fees quoted for procedures are ESTIMATES ONLY based on the anticipated procedure and current information provided to the office by the insurance carrier.

Two (2) statements will be provided after insurance payment for a given date of service.   If no payment is received prior to the second statement being mailed, the third statement will be marked “Final Notice” and may be sent to an outside collection service if payment arrangements have not been made.   The patient is responsible for any fees associate with collection, interest or legal expenses associated with the collection process.   Prior authorization by the insurance carrier is not a guarantee of payment, and the patient is responsible for any bills not paid by the insurance carrier.

Patients may be charged a fee for failure to cancel an appointment which is not kept 24 hours in advance.   These fees are posted in the office.

If insurance has pended or denied a claim due to reasons beyond the control of the office (e.g. pending or denied pre-existing conditions, pending additional information from member, denied member covered under another health plan, etc.), a final statement will be sent with balance due within 30 days of the notice from the insurance carrier.

Patients must sign paper work authorizing payment of medical benefits to the office for services rendered, as well as services not covered by the insurance carrier.   This includes collection costs, attorney fees, and other collection costs that may be incurred to enforce collection of outstanding balances, as well as a release to send medical information necessary to complete and process insurance claims.

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