We are pleased you have chosen our practice as your healthcare provider.  It is our goal to provide you with the highest quality healthcare services possible.   

 

The purpose of this Financial Policy is to help avoid misunderstanding about billing and payment for our professional services, and to help us to provide the best possible medical care while controlling administrative costs.  The following is a statement of our financial policy, which we ask that you read and acknowledge with your signature.

 

• All patients should provide accurate and complete personal and insurance information prior to being seen by the provider.  All insurance cards should be shown at each and every visit.

• All applicable, co-payments, personal balances, both current and prior, are due at the time of service.

• We accept cash, check, Visa, MasterCard, and Discover credit cards.

 

Regarding Insurance

Our practice participates with many health insurance companies.  It is your responsibility to comply with any predetermination of benefits or referral requirements.  Please be aware that some, and perhaps all, of the services provided may be non-covered services per your insurance plan.  Our billing department will submit a claim for any services rendered to a patient who is a member of our participating insurance plans.  If a patient is a member of an insurance plan with which we do not participate, our office will also file a claim on the patient’s behalf, but we will expect payment in full at the time of service. 

 

You are responsible for contacting our office to request a referral or authorization required for any visits your insurance deems necessary.  This request should be submitted within 72 hours prior to the date of the office visit due to the processing needed to obtain referrals. 

 

In the event of a personal financial hardship, we are able to offer special financial arrangements, including payment plans.  Financial documents will be requested for any financial hardship. 

 

Billing Statements

A billing statement covering any balance due for services rendered will be sent to you on a monthly basis.  If you cannot pay the balance in full, please contact our billing department to make payment arrangements (610-973-1410). 

 

Returned Checks or E-check:

If a personal check or e-check is returned from your bank account for any reason, your account will be charged a $20.00 return check fee.

 

Past Due Accounts

Accounts that are past due will be referred to our Collection Agency.

 

Children Accounts

An adult accompanying a child under 18, and/or the parent or guardian of a child is responsible for payment according to terms described above.  We do not get involved in any custody arrangements for payment. 

 

Completion of Forms

When requesting the completion of forms at a time other than your office visit, please be aware that your physician reserves the right to charge a fee depending on complexity.

 

Copying Medical Records

Please be aware that we reserve the right to charge a medical records copying fee in accordance with Act 26.  We do not seek to make a profit on providing medical records, rather to recover our costs for copying them.

 

I authorize and assign insurance benefit payments directly to LVPG MATLV for any medical services I receive.  I understand and agree that I am ultimately responsible for the charges on my account for any professional services rendered that is not covered by my insurance company.