Financial and Administrative Forms Policies
Financial Policy (effective 1/1/2017)
Our priority is to provide exceptional medical care to our patients.
We value our relationship with you. Please read this financial
policy carefully to prevent misunderstandings. Thank you.
It is your responsibility to keep the practice updated with your
most current information (insurance, address, phone numbers,
emergency contacts, etc).
Any questions regarding benefit
issues or physician participation status should be directed to
your insurance company. We will help with what we can
but we don’t know each contract and its benefits
We expect any copay to be paid at the time of
service. If payment is not made at the time of the service a
$10 administrative fee will be added to your
account. It is part of your contract with your insurance for
you to pay your copay at the time of service
We are collecting partial payment
for the high deductible insurances at the time of your
visit. We will bill you for any remaining balance after your
insurance processes your claim. We make every effort possible
to determine what is allowed by your insurance. We realize
there could be a conflict with your HSA or FSA account if an
overpayment is made. Please be aware of your deductible
We will file a claim on your behalf to all insurers with whom we
are currently participating. If we are not participating with
your insurer, you are responsible for paying in full at the time
of service. We do not participate
with all insurers so please check with your insurance to verify
that you are covered here. Some insurers require you to
list a Primary Care Physician (PCP). Please make sure
one of our doctors is listed so they will pay for your visit
Many offices do not bill a secondary insurance company, but we
will bill most secondary
insurances as a courtesy to our patients. Please make certain
you have all your current insurance information available at
check in so we are able to provide this service. We will not
submit for a copay in many instances.
We will submit for motor vehicle accident (MVA) claims but we
do not submit for Workers’
Compensation or any liability claims. We do not treat workers’
compensation injuries, therefore, we refer you out to someone
There is an administrative charge of $15 for the
completion of forms that require a provider to review
your chart and sign the form. This fee is waived if the form is
presented at the time of a scheduled appointment.
Returned checks will incur a $20 returned check fee.
In the event of a second returned check, your
privilege to pay by check on future visits will be terminated
and you will be expected to pay with cash or credit card.
We require prior notification
(minimum of 4 hours) if you are unable to keep your appointment.
There will be a $40
charge for all missed appointments. Chronic
missed appointments could result in termination of care.
It is understood and agreed that in the event any outstanding
balance has to be referred to a collection agency or attorney
for recovery, the patient will be fully responsible for any
cost, including, but not limited to attorney’s fees. If there
is no response to our continued efforts to reach the patient by
phone or mail the patient will be told to seek medical care
elsewhere. We work very hard to help you keep this from
happening. Please keep in touch with us if there is a financial
We require that you sign a payment plan agreement if you
are unable to pay the entire balance on your account by the due
date. The amount paid each month will be determined by Hilton
Health Care and must be paid in addition to any additional
charges each month. It is your responsibility to make the
monthly payment on time without additional reminders.
Administrative Forms Policy
As of 11/1/2016, there will be a charge for completion of any
form(s) not submitted at the time of an office visit. There will be
a $15.00 charge for completion of ALL forms not submitted at the
time of an office visit. This fee is due at the time the form is
This charge is necessary due to increasing demands on providers’
time and increasing office expenses.