Your insurance contract is an agreement between you, your insurance company and in
many instances, your employer. All charges incurred at Weaverville Family Medicine
are your responsibility. Any disputes with the insurance company should be handled by
you. You will be expected to pay your portion of the total charges at the time of service,
even if we do not participate with your insurance company. As a courtesy to you, we will
file a claim to your insurance company ?assigned? to us so the insurance portion will come
directly to Weaverville Family Medicine. As a courtesy to you, we will file your
secondary insurance once we have received a response from your primary insurance. We
will give the secondary 45 days to respond to the claim, and if no response is received the
balance on the account will be turned over to you. It will become your
responsibility to contact the secondary for payment. The secondary insurance will be
filed only once, as a courtesy to you.
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1. Payment is due when services are rendered. We accept cash, personal checks and most major credit cards. There is a $30.00 charge assessed for all checks returned by your bank for non sufficient funds. If you are a self-pay (uninsured) patient, a $100.00 deposit will be required at check-in for your initial visit. This covers the "approximate" total for your visit. Any additional charges will be collected at check-out.
2. Payment plans on self-pay and past due patient balances will be considered on a case- by-case basis. This should be discussed with a billing office representative and approved by a Patient Account Manager. Patients will not be permitted to carry a balance larger than $250.00. If your balance reaches $250.00 you will be required to pay in-full for any additional visits or charges.
3. When you check out, charges will be assessed based upon the nature of your visit. However, there may be additional charges that may not have been noted on the encounter form by your provider that will be billed after your visit.
4. If you are insured with Medicare, Medicaid, Blue Cross Blue Shield, United Health Care, Medcost, Healthcare Savings, Cigna or Crescent, we will accept the co-payment or co-insurance, then file the insurance for you at no cost.
5. Concerning minor children, the person bringing the child in is responsible for the bill.
6. We consider an account delinquent if not paid within 30 days from billing date. After 90 days of non-payment, further action may be taken to recover this delinquent account, i.e. a collection agency, and possible dismissal from the practice.
Please sign below that you have read, understand and will abide with this Weaverville Family Medicine, P.A. Financial Policy.
Patient's Name _____________________________ Signature: ____________________________________
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