Valley Family Medicine - Financial Policy

Thank you for choosing us as your health care provider. We hope that we are able to provide your medical care in a way that is comfortable and convenient for you. If there is anyway that we can be of better service, please do not hesitate to let us know.

We will gladly bill your insurance for any and all fees. Please keep in mind that we bill your insurance company as a courtesy to you and that it is not a guarantee of payment. If for any reason your insurance does not pay or pays an incorrect amount, it is your responsibility to follow up with them. This will allow us to help keep fees lower by eliminating costly multiple billings. If you have an HMO, PPO, or Medical Assistance, your co-pay is due prior to treatment. We accept payment with cash, debit card, check or credit card.

If you have no insurance, payment in full is expected at the time services are rendered. If you have some special financial circumstances that would prevent you from paying your bill in full, or if you are an obstetrical patient, please discuss it with my staff prior to the day of your visit as alternate arrangements can be made for you.

Any unpaid balance that is more than 90 days old will be subject to an interest charge. Interest is applied at a rate of 1% per month every month there is an unpaid balance.

Our office also has a cancellation policy. To reschedule or cancel appointments please notify us. We reserve the right to charge $25.00 for failed appointments.

Our practice is committed to providing the best treatment for our patients and we usually charge what is usual and customary for our area. Your are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rate.

Thank you for your kind consideration in this matter.

I have read the above financial policy and understand my financial obligations.

        X____________________________________________________
             (Signature of patient or responsible party)