Office and Payment Policies

Printable PDF Office and Payment Policies

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Office and Payment Policies

After 2016 Dr. Garcia’s office will accept no insurance. Effective January 1, 2017 Dr. Garcia will be out of network for all insurance plans. As of January 1, 2017 Dr. Garcia’s office will be unable to file any medical insurance claims. A detailed receipt can be provided for patients to file for out-of-network benefits.
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Charges (co-pay/deductibles): Full payment is due at the time services are rendered unless other payment arrangements have been previously made. This includes all co-payments and deductibles which are part of your contract with the insurance company. Failure to pay is considered a breach of your contract with your insurance company and you will be responsible for the full billed amount as we would be unable to honor the contracted write-off amount. We accept MasterCard, Visa, Discover, American Express, and Cash, and will hold a check for up to one (1) week with administrative approval.
NSF/Closed Accounts: There will be a charge added to your account for all returned checks.

Insurance/Claims Submission/Non-Covered Services: Knowing your insurance benefits is your responsibility. Your insurance company may need you to supply certain information directly and it is your responsibility to comply with their request. We will gladly file your claim, however, if the insurance denies payment for services (including but not limited to: labs, injections, immunizations, minor surgical procedures) you will be billed and responsible for payment. You must contact the insurance to dispute any denial or non-payment issues as this is your contract with them. If Dr. Garcia is not listed as the Primary Care Physician or PCP, we reserve the right to not see the patient until the issue is resolved.
Proof of Insurance: Insurance cards must be available at all office visits. If we are unable to verify your insurance we reserve the right to reschedule your appointment or to collect the full amount until eligibility and/or verification of benefits can be confirmed. It is your responsibility to inform the office of any insurance changes and failure to do so may result in claim denial, making you responsible for the full billed amount.

Appointments: If you are going to be 15+ (fifteen or more) minutes late to your appointment, you will be asked to reschedule the appointment. If you insist on being seen that day, you will be charged a $20 late fee, which will not be paid by insurance. We request 24-hour notice for cancellations. If a patient or family member does not inform the office before the appointment time that they cannot make the appointment a $35 fee will be applied to your account and must be paid prior to your next visit. At the 4th missed appointment, the patient/family will be dismissed from the practice.

Non-payment: Failure to pay your account when notified of a balance may result in dismissal of you and your immediate family members from this practice. All unpaid balances over 120 days old will be referred to an outside collection agency.

Paper Work/Shot and Medical Records: All fees are due at time of request. Please give us two weeks (2) for completion of Paper Work, or Medical Records. There is a $35.00 charge for paperwork that must be completed by any member of this office. The fee must be paid at time of request. This includes forms such as FMLA, Short Term Disability, and Insurance related forms. Hand-written shot records are $5 for each replacement or copy. The MA’s must have 1-2 business days to complete the Shot Record. To receive Medical Records for yourself or a dependent, a payment of $35 is required at time of request.

Medication Refills: The method for pharmacies to request a refill is to submit an order electronically. A fax is not an electronic request. If the request is faxed, your refill will be delayed. Refills will only be handled during normal office hours Monday-Friday. Prescriptions for Narcotic and Controlled Medications are required to be picked up, as a hard-copy, from the office and will not be refilled after office hours or on weekends.

Referrals: Allow 5-7 business days for all routine referrals. If one does not get a confirmation from either Dr. Garcia’s office or the Clinic in receipt of the referral, please don’t hesitate to call us after 7 days.

Behavior: Physical and/or verbal abuse towards the office staff or physician will not be tolerated. This includes disruptions affecting daily operations within the office as well as offensive behavior on the telephone. Abusive behavior will result in immediate dismissal from the practice.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding the above policies. Please let us know if you have any questions or concerns.

I have read and understand the office payment policies and agree to abide by them.

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Signature of patient or responsible party Date

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Printed name of Responsible Party Printed Name of Patient if different