Financial Policy, May 2008

This financial policy contains important information about billing and payment for our professional services. It is intended to help ensure the best possible medical care for our patients, while also controlling administrative costs. It outlines our responsibilities, and those of our patients, with regard to billing and payment for our services.

• Our practice participates with many health insurance companies and managed care programs. Our business office will submit a claim for any services rendered to a patient who is a member of one of these plans. Patients must provide all necessary insurance information and complete any required forms before leaving the office.

• If a patient is a member of an insurance plan with which we do not participate, our office will also file the claim on the patient’s behalf; however, the patient is expected to make payment in full at the time of service.

• It is the patient’s responsibility to make payment at the time of service for any co-payment or co-insurance due. Any services not covered by a patient’s insurance plan are the patient’s responsibility and payment in full is expected at the time of service. Failure to make a co-payment on the day of service will result in an administrative charge of $15 in addition to the co-payment..

• Payment for professional services can be made by cash, check, credit card or debit card. We accept VISA®, MasterCard®, American Express® and Discover® Card.

• CapitalCare Medical Group charges a fee of $20 for each check returned for insufficient funds.

• It is the patient’s responsibility to ensure that any required authorization or referral for treatment is provided prior to the visit. In the absence of a required authorization or referral, the patient’s visit may be rescheduled or the patient may be personally responsible for payment for the services rendered by CapitalCare Medical Group.

• It is the patient’s responsibility to provide us with current insurance information and to present an active insurance card at each visit.

• Our staff is happy to help with insurance questions relating to a claim that has been filed, or to provide additional information required by the insurance carrier to process the claim. However, patients should direct questions about coverage for specific procedures to a representative of their insurance company’s member services department. The phone number for member services is usually on the insurance card.

• An adult accompanying a child under 18, and/or the parent or guardian of the child, is responsible for payment according to the terms described above. Non-emergency treatment for children unaccompanied by an adult may be rescheduled by CapitalCare Medical Group unless charges have been pre-authorized, or payment by credit card, debit card, cash or check at time of service has been arranged.

• If a patient requires the completion of medical forms at a time other than an office visit, each form will be subject to an administrative fee of $15.00.

• If a patient requests a refill of a prescription for a controlled substance between office visits, CapitalCare will charge a fee of $5.00 for each prescription, except when prohibited by regulation.

• Please understand that when a patient does not cancel an appointment he or she is unable to keep, it may prevent other patients from receiving care they need. Therefore, CapitalCare charges a fee of $25 for appointments not canceled with at least 24 hours’ notice. A patient who fails to keep three or more appointments in a twelve-month period—without prior notice of cancellation—may be discharged from CapitalCare Medical Group at the discretion of the patient’s physician.

In the event of personal financial hardship, CapitalCare Medical Group is able to offer special financial arrangements, including payment plans.

We firmly believe that effective communication is the key to a successful physician-patient relationship, and we are eager to help in any way we can

Please direct questions about payment for services to our Billing Department at (518) 452-1337 or by email.