Last updated: December 14, 2023
Thank you for choosing Elite Screening and Wellness as your healthcare provider. Our goal is to build a successful provider-patient relationship with you. Understanding our patient financial policy and your responsibility for service payment is essential to our professional relationship. If you have questions about our fees, our policies, or your responsibilities, please ask. You are responsible for notifying our office of any changes in your address, name, telephone, insurance information, etc.
The Nurse Practitioner service is provided directly to you and not to an insurance company. Insurance is a contract between you and your insurance company. We will bill your primary insurance company as a courtesy to you, requiring you to assign benefits allowing the insurance company to pay the provider directly. To properly bill your insurance company, we need you to provide all insurance information, including primary and secondary insurance, and any changes in insurance information.
You are expected to present an insurance card at each visit.
Co-payments and past due balances are due at check-in unless prior arrangements have been made and approved. You may pay by cash, check, money orders, or credit card.
Co-insurance, deductibles, and payments for non-covered services, and any other portion of these services not paid by the insurance company and not usually adjusted, as part of our contractual agreement with the insurance company will be your responsibility. Payments for known deductibles, etc., are due when services are rendered. The insurance company makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, i.e., if the practice is not part of your insurance’s network, you agree to pay all charges not covered by insurance.
Not all services provided by this office are covered by every plan.
You are responsible for understanding your benefit plan and its requirements for referral to specialists, preauthorization of procedures, etc. It is your responsibility to pay for non-covered services. After instance, claims are paid, and remaining balances are payable in full within the regularly scheduled billing cycle (usually 30 days).
If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately. The patient is responsible for knowing if our office participates in their plan.
We do not submit claims to secondary insurers on your behalf. We will provide you with a receipt to submit for reimbursement. Your secondary insurance will send the reimbursement check directly to you. You are responsible for any balances on your account.
Payment of past due balances must be made before a scheduled appointment.
Patients without insurance are expected to pay for services during the visit. [If your office offers a discount for services paid for at the time of services, you may want to mention that here).
This office understands special needs. Setting up a payment plan for a patient undergoing extensive treatment may be necessary. If this situation is essential for you, please speak with a [Financial Counselor, office manager, or whoever authorizes this in your office] to discuss a mutually agreeable payment plan.
Worker’s Compensation and Automobile Accidents
We do not handle workers' compensation r/t automobile accidents.
If you must cancel an appointment, please give us at least  hours' notice to allow us to offer the appointment to another patient. Failure to keep appointments without proper notice may be a fuse for discharge from the practice to care for other patients.
A returned check charge of $25.00 will be payable by cash or money order (or credit card) along with the fee for insufficient funds rendered by the bank. This must be paid before being seen. A returned check may be cause for providing services on a cash-only basis. We do not accept checks.
Medical Record Copies
Charges for copies of medical records will be discussed upon request.
Patient Requested Medical Forms and Letters
Charges to complete medical forms (handicap parking, driver’s license, assisted living, insurance, etc.) are (in most cases) not covered by insurance and are, therefore, the patient's responsibility. Fees for this service will vary according to the complexity of the form or letter. Please contact our office to let us know what you need so we can provide you with a quote for the service.
If previous arrangements have not been made with our financial office, any account glance outstanding over 90 days will be forwarded to a collection agency.