Jeffrey F. Klein, M.D., F.A.A.F.P. - A Medical Corporation




	Patient Financial Policy

Jeffrey F. Klein, M.D., Inc. "Patient Financial Policy"

Thank you for choosing our practice! We are committed to the success of your medical care. Please understand that payment of your bill is part of this care. To help avoid misunderstandings, our financial policy is in writing. For your convenience, we have answered some commonly asked questions below. If you need further information, please ask to speak with a Billing Specialist from Accuquik, our billing service.

How may I pay?
We accept payment by cash and check, or by VISA or MasterCard.

What if my child needs to see the physician?
A parent or legal guardian must accompany patients who are minors on the patient's first visit, and must sign the financial statement for the patient, accepting responsibility for the account.

What is your policy regarding missed appointments?
Patients who do not show up for an appointment, and do not call to cancel have impacted other patients' ability to obtain timely medical care. Therefore, subject to the individual patient's insurance contract, we reserve the right to charge for missed appointments.

Do copays need to be paid at the time of my appointment?
Yes. According to your contract with your insurance company, all copays are to be paid at the time of service. Refusal to abide by this agreement may result in termination of your coverage.

What if my check bounces?
If a check is returned for insufficient funds, of if payment has been stopped, you will be charged a $25 fee in addition to the amount of the check. If you have a second check returned, you may be asked to pay by cash, money order or cashier's check, or credit card.

How am I to pay my part after you bill the insurance?
Once we receive the Explanation of Benefits from your insurance company, we will bill you for the balance that you owe. That amount is due upon your receipt of the statement. If we need to resend a statement, you may be charged a $10 rebilling fee, subject to your insurance contract.

What if I do not pay my bill?
Accounts that are repeatedly ignored may be sent to collections. If this happens, you may have your credit adversely affected, and you will be dismissed from the practice and asked to find a new physician.

What is my financial responsibility for services?
Although summarized on the reverse, this depends on a variety of factors and we suggest you call your insurance.

What about "Non-medically necessary" procedures?
If you and your physician decide on a procedure that is not medically necessary (usually cosmetic procedures such as moles, spider veins, or skin tags), you will be asked to pay the estimated cost of the procedure prior to the procedure being done. You will then be balance-billed or refunded the difference.

Can I just pay my balance by credit card?
Yes. We now offer the convenience of paying your coinsurance (your share after the insurance has paid) via credit card with our Easy Pay Option. To do this, you simply have to fill out a brief authorization form. Once your insurance has paid, your card will be charged the "patient due" portion. No bills to bother with! Just ask for an authorization form.

Acknowledgement

I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance, as well as applicable co-payments and deductibles, are my responsibility. I authorize my insurance benefits be paid directly to Jeffrey F. Klein, M.D., Inc. and I authorize them to release any pertinent medical information to facilitate payment of a claim.

I have received a copy of this policy. TO PRINT THE FINANCIAL POLICY OUT, CLICK HERE.

Date, Signature of Responsible Party, Printed Name, Patient Name (if different)

Your Responsibilities for Office Visits and Office Services*

If You Have...
You Are Responsible For...

Commercial Insurance
Also known as indemnity or "80%/20% or 90%/10% coverage."
Payment of the expected patient responsibility for all office visits, injections, and other charges at the time of office visit.

We suggest that you call your insurance company ahead of time to determine deductibles and coinsurance.

We will file an insurance claim as a courtesy to you.

HMO & PPO plans with which we have a contract
If the services you receive are covered by the plan: All applicable copays and deductibles are requested at the time of the office visit.

If the services you receive are not covered by the plan: Payment in full is requested at the time of the visit.

We suggest that you call your insurance company ahead of time to determine copays, deductibles, and non-covered services for you.

We will file an insurance claim as a courtesy to you.

HMO with which we are not contracted, or Medicare HMO
Payment in full for office visits, injections, and other charges at the time of office visit. (We will provide the necessary information for you to file your claim directly with the insurance company.)

Point of Service (POS) Plan or Out Of Network PPO
Payment of the patient responsibility-deductible, copay, non-covered services-at the time of the visit.

We suggest that you call your insurance company ahead of time to determine benefits, copays, deductibles, and non-covered services.

We will file an insurance claim as a courtesy to you.

Medicare
If you have Regular Medicare, and have not met your $100 deductible, we ask that it be paid at the time of service.

Any services not covered by Medicare are requested at the time of the visit.

If you have Medicare as primary, and also have secondary insurance (Medigap): No payment is necessary at the time of the visit.

If you have Medicare as primary, but no secondary insurance: Payment of your 20% copay is requested at the time of the visit.

We will file an insurance claim to Medicare and your secondary as a courtesy to you.

Worker's Compensation
If we have a verified claim and authorization to treat from your carrier: No payment is necessary.

If we are not able to verify your claim or get authorization to treat: Payment in full is requested at the time of the visit.

We suggest that you call your carrier ahead of time to verify the claim number, authorization for us to treat, and referral procedures.

No Insurance
Payment in full at the time of the visit. If the total cost of the visit is not able to be determined, you will be asked to make an estimated payment and will be billed or credited the difference. We will work with you to settle your account. Please ask to speak with our staff if you need assistance or regarding an extended payment schedule.

*This is only meant as a guide. Please check with your insurance company for more details.

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This site is for information only. It is not intended to replace consultation with your physician.