St Lawrence Health Alliance, Inc.
3 Lyon Place Suite 200
Ogdensburg NY 13669
OUR FINANCIAL POLICY
Thank you for choosing our office as your health care provider. We are committed to the provision of excellent service. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign.
All patients must complete our information and Insurance form before seeing the doctor. You must provide your insurance card.
Full payment is due at time of service unless the doctor is participating with your insurance provider.
We accept cash, checks, or Visa/Master card.
We offer extended payment plan.
Regarding Insurance:
We may accept assignment of insurance benefits if the doctor is enrolled as a participating provider with your insurance. The balance is your responsibility. We cannot bill your insurance company unless you give us insurance information. Please be aware that some and perhaps all, of the services provided may me non-covered services or considered reasonable and necessary under the Medicare program and/or other insurance. If so, it is your responsibility to pay for these services.
Regarding Insurance Rates:
Our practice is committed to providing the best treatment for our patients. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy.
X_________________________________________________
Date:_________________________________
Signature of patient or responsible party
ASSIGNMENT OF BENEFITS & AGREEMENT FOR PAYMENT
I hereby authorize my insurance company and/or Medicare to pay Dr.________________________ directly. I hereby authorize the release of necessary medical information to process this claim for myself and/or my dependents.
I understand I am responsible for fees my insurance company does not cover or balances not paid by my insurance company.
X_______________________________________ Date:____________________________
Witness:_____________________________________ Date:____________________________