FINANCIAL POLICY & AGREEMENTS

Introduction
The clinic of Pamela L. Vincent MD, P.C. is a professional business providing health-related diagnostic and therapeutic services to its patient and clients with the expectation of making the profit needed to financially support its employees and their families, to pay its necessary expenses, and to develop future new services.

A professional relationship requires honest financial accountability. This document states the policy by which Pamela L. Vincent MD, P.C. will hold itself and its patients and clients accountable.

Charges for Professional Services
Every professional service and associated expense rendered will be charged to the patient according to a fee schedule prospectively determined by the clinic. Contractual discounts to third parties prospectively agreed to by the clinic will be honored in good faith. No fee or charge can be reduced or waived without the permission of only the administrator, billing manager, or his or her designee.

Monthly statements of payment transactions and the total amount owed will be sent until the debt is totally satisfied.

Payment
Payment for services rendered is due on the date of service and is part of the professional relationship. Pamela L. Vincent MD, P.C. reserves the right to request payment of the total negotiated fee on the date due unless directed otherwise by contract. Cash, check, money order, Visa, MasterCard and American Express will be acceptable methods of payment.

All co-payments and deductibles will be collected at the time of service. Failure to pay your copay at the time of service will result in a $15 charge added to your balance due. Unless insured patients can provide documentation that the deductible has been met, then payment for services will be based on the deductible having not been met. Unless insured patients can provide documentation of the co-payment amount, 20% of the fee will be due at the time of service.

Non-urgent professional services may be delayed or terminated within the guidelines of good medical practice for bad-faith patient noncompliance with this financial policy. Only the administrator, billing manager, or their designated representative can amend this policy.

Self-Pay Patients
Self-pay patients must pay in full at check-in. We reserve the right to refuse service to any patient for failure to pay. The self-pay charge for an office visit does not include charges for any procedures the provider may perform.

Forms
All forms including driver license ability forms and work ability forms that the patient requests to be completed by a provider may require payment for this service.

Insurance
Health insurance is primarily a contract between the patient and the insurance company; however, Pamela L. Vincent MD, P.C. also has mutually agreed contractual obligations with certain private and government entities. The patient is primarily responsible for holding the insurance company accountable for claims reimbursement. Pamela L. Vincent MD, P.C. will make available substantial resources to facilitate insurance payment and will dedicate its resources toward its own contractual obligations with these entities.

Credit
Credit will be extended for 60 days to patients with valid insurance policies applicable to the charges for services after fulfillment of appropriate deductibles and co-payments. After 60 days, this credit will be revoked and all payments will be immediately due. A finance charge (1.5% per month / APR 18%) may be added to any amount for which payment has not been received within 60 days from the date of service corresponding to the charge. The account must be paid within 90 days or a finance charge will be added on a monthly basis. A 20$ service charge will be incurred for each check or other instrument tendered but returned for any reason.

Collection Agencies
Pamela L. Vincent MD, P.C. will use all reasonable means to collect owed funds. Defaults in payment of amounts due will be automatically referred to a collection agency for payment. A 33 1/3% collection fee and/or legal fees of 50% of the total amount due will be added to accounts if sent to a collection agency. Additional service charges may be levied for accounts placed with third-party collection agencies or failure to make necessary co-payments at the time of service.

Responsibilities of Patient
The patient is to contact the insurance company and/or third parties for necessary pre-certifications needed for insurance or third-party payment prior to the office visit. The patient likewise must familiarize himself or herself with the pre-certification requirements of the third-party payer for services rendered out of the office. A telephone number on the back of the insurance card can usually be used to obtain this information.

At each office visit or patient encounter, the patient will provide a current mailing address and telephone number as well as third-party information necessary for billing purposes. This information must be given primarily to a billing representative or receptionist. The doctor or nurse will need to know the identity of the insurance company to make proper referrals under the managed care contract; thus, proper identification is mandatory.

Before each office visit the patient will speak with a receptionist or billing representative to make payment arrangements for the services rendered.

The patient is to contact his or her insurance company if payment is not made within 60 days.

The patient is to immediately make total payment when the debt is due.

The patient is to proactively prospectively discuss extenuating circumstances with the Clinic.

Responsibilities of the Clinic
The clinic will make a best effort to obtain necessary pre-certifications for requested procedures required by contracted third parties to facilitate approval for payment thereof. Failure to obtain pre-certifications or approval from the insurance company does not necessarily mean that requested procedure is not medically necessary; in this circumstance, the patient may be financially responsible for services ordered or rendered.

Upon receiving accurate third-party information, the Clinic will file an appropriate AMA-approved claim to the appropriate entity. The Clinic will make a good-faith effort in concert with the patient to follow up these claims to facilitate payment.

The Clinic will uniformly and fairly enforce this policy and procedure upon all patients.

OFFICE POLICIES

Financial Policies
Please read the PATIENT FINANCIAL POLICY & AGREEMENTS for further information regarding your financial obligations.

Medications & Refills
Always bring a current list of your medications to your appointment and give it to the receptionist.

Medication refill requests can be left on the phone messaging service; we will generally call in refills after clinic hours; please allow at least 24 hours for refills.

Refill requests must be called in before noon on Friday to be filled before the following Monday.

Pain medication such as narcotics cannot be refilled early, will not be refilled if lost, and are not refillable by the doctor or provider on call. Pain medication will be refilled or discontinued at the provider’s discretion.

Please be very careful not to run out of essential medications, such as seizure medications, before your next visit.

Appointments
We rely on you to keep your scheduled appointments. You will be charged $35 for a missed appointment unless you notify us 24 hours in advance. This will be your responsibility, your insurance will not be charged. If you miss 3 appointments, we reserve the right to decline further appointments.

Results, Diary, Medical Records
If you are asked to keep a symptom diary, obtain medical records, bring in test results, such as MRI scans, please remember to do so.

Other
Our association with Integrated Healing Arts-Utah allows us to offer complementary and alternative approaches to management of some medical problems; if this is of interest to you, please request referral or more information.

We reserve the right to refuse service for any reason.

Please let us know how we can better serve you and meet your expectations.