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Financial Policy

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Alpine Allergy & Asthma Associates, Inc. Financial Policy 2012
We are dedicated to providing the best possible care for our patients. To ensure we run an efficient practice and to better serve you, the following is our financial policy.

Payment Options: Payment for co-pays, amounts toward your deductible and non-covered/cosmetic services are due at the time of your appointment. We accept the following credit cards: Visa, Master Card and Discover.. Patients with HSA (Health Savings Accounts) are responsible for payment at the time of service. An itemized receipt will be provided for patients to receive reimbursement from their HSA.

Insurance:
If we are not contracted with your insurance, or you have no insurance, you are responsible for payment in full at the time of service. Due to strict insurance billing time limits, patients who do not bring their insurance cards to their appointments will be considered cash patients.

Depending on your procedure and the complexity of your visit, we will not know the exact amounts that your insurance will cover. In this case, we will request a partial payment at your appointment.. We will bill your participating insurance company as a courtesy to you, however, you are responsible to know what is and is not covered by your insurance plan. If applicable, it is also your responsibility to obtain and keep track of referrals, number of visits available , referral expiration etc,. although we may assist with the process.

.If your insurance chooses not to pay for your services. for any reason, or if there is a delay in payment, you are ultimately responsible for payment. If we have not received payment from your insurance company within 45 days,. you will be expected to pay the balance in full. Our billing office is available to assist you if you have any questions. Billing Statements: We will send you a statement if you have a balance due. .In the future we may charge for multiple billing statements.

Delinquent Accounts: Our office does not carry account balances. If your account goes over 60 days without payment, we will assume that you will not be paying.. If your account is sent to collections, you are responsible for payment of any applicable fees. You will not be given the opportunity to set up a new appointment until your account balance is paid in full. Accounts that are current but have collection history will require cash payment at the date of service.

Returned Checks: If your check is not honored by your bank, we will assess a $25.00 NSF fee for the first check and $35.00 for each additional checks. .If you do not pay for the returned check and fees, you will be responsible for charges according to CA Civil Code section 1719.

Canceled, Late and Missed Appointments: If you must cancel your appointment, we kindly require 24 hour notice. For accounts with chronic no-show or less than 24 hr cancellation notice given for appointments, there will be a $40.00 fee charged for missed appointments.

Copies of Medical Records: All requests for medical records require a signed authorization. There is a $25.00 charge for medical records and we require 10 business days to complete your request.

I have read and understand the financial policy of Alpine Allergy & Asthma Associates, Inc.

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Signature of Patient/Responsible Party..___________________.Date____________

Please Print Full Name ____________________________________________

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