AACPC will bill my insurance provided all the necessary information is given to the clinic at the time of service. This includes a valid, current insurance card. If this is not available, I will be asked to pay all charges for the day’s visit before I leave the office. AACPC will ask to see a copy of your insurance card at every visit to ensure that we have all of the proper billing data and that the card is current.
If my insurance company does not submit payment within 30 days, I understand I will be responsible for any and all outstanding balances. I am aware that my insurance carrier, rather than my physician, may deny some services for the reason of “not being medically necessary” or “non-covered” services, therefore, I will become fully responsible for payment of these services.
If I have asked for an estimate of cost for my visit, this will be given as closely as possible. However, since AACPC is not aware of the exact numbers of skin tests, level of care, etc. that will be needed until the physician has seen the patient; this is to be considered only as an estimate and not an exact charge quote.
My responsibility will be my co-pay (required at time of service), deductibles, coinsurance, or any other amount that my insurance company deems my responsibility. I will also be responsible for services not covered under my policy, delivery fees and no-show fees.
I am responsible for making sure that there is a current and valid referral and/or precertification prior to any procedure or office appointment, if my policy requires one. If no referral and/or precertification is rendered, the balance is my responsibility.
AACPC will make all attempts to collect payment from the insurance carrier; however, I am ultimately responsible for all costs associated with my visit. Though insurance coverage may be carried, it is not a guarantee of payment. I understand that if my insurance company fails to pay AACPC, any remaining balance will be my responsibility and will be paid in full upon receiving a statement of balance. I will pay this balance within 15 days or contact the office to make financial arrangements. I agree to allow AACPC to telephone me at any of my phone numbers given to AACPC to discuss any issues regarding payment of my account. A late fee of $20.00 will be assessed if my account is not paid by 45 days. All bills must be paid in full within 57 days or my account may be sent to an outside collection agency. Once this is done, I must deal directly with the collection agency and not AACPC as it is out of their hands to do anything with my account. This agency will add the appropriate fees for collection if my account is sent there. At this time AACPC will cease giving care to me and all other family members.
ALL INSURANCE COVERAGE IS A MATTER BETWEEN THE PATIENT AND THE INSURANCE COMPANY, AND THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT.