Answer: What is your payment policy?

Thank you for choosing Bayshore Family Medicine as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance financial responsibility for services rendered, we have developed this “ Financial Agreement”. Please feel free to print it out and read it thoroughly. You can either bring this signed copy with you to your next office visit or we will have you sign a copy at your next office visit. Again, please read it, and if you have any questions, feel free to ask. A copy will be provided to you upon request.

Insurance ~ Your insurance policy is a contract between you , your employer, and your insurance company. You are responsible to know and understand the coverage’s and deductibles of your insurance plan and that insurance is only a method of reimbursing you for fees due and is NOT a substitute for payment.

Unless prior arrangements are made or you have insurance coverage, accounts are to be paid in full on the date services are rendered.

Claims Submission

Cancellation/No Show Policy ~ Any cancellations with less than four hours notice of not appearing for a scheduled appointment may incur a separate fee of $25.00. This charge is not covered by insurance and must be paid in full prior to your next appointment.

NSF Checks ~ If you write an NSF check (non-sufficient funds) or stop payment on a check or credit card payment you will incur a $25.00 administrative fee, which will be added to your account.

Minor Patients ~ The adult accompanying a minor or the parents (or guardian of the minor) are jointly and severally responsible for full payment of services to the minor.

Patient Information ~ For proper billing and insurance reimbursement current information is necessary. Please keep the office updated on all information necessary for treatment and billing. You will need to provide current residence, employment, insurance addresses and phone numbers as they change. This office collects administrative and non-medical patient data including social security numbers for the purpose of patient identification, compliance with federal and state agency reporting requirements, billing to insurance carriers and obtaining payment. Disclosure of social security number is voluntary.

Monthly Statements ~ You will be billed monthly and this statement will reflect all charges for services rendered and payments received to the date of the bill. The charges shown on these statements are presumed to be correct and reasonable unless protested in writing within thirty days of the billing date.