For your convenience, we’ve made pre-admission forms available. If you wish, you may print these forms and fill them out before your office visit in an effore to decrease any wait time.
Advance Beneficiary Notice
Financial Responsibility
Patient Information Release
MRI Evaluation
Upon arrival, patients are asked to register at the reception desk. A receptionist
will ask for insurance cards and driver’s license or similar
proof of identification. All patients will be asked to review a financial
responsibility form and sign. The receptionist will begin your registration
process immediately upon your arrival. Generally the process may take a few
minutes to complete. Afterwards the technologist will meet you to begin the
procedure.
When the procedure is over the technologist will escort you to
the waiting room so you may leave. In most cases we will bill
you for any uncovered portion of service. This will include
deductibles or co-pays required by your insurance. We often have
no knowledge of the amount prior to receiving an explanation
of benefits from your insurance plan. Your financial responsibility
is determined by your insurance plan, not by us. If you are responsible
for any portion of your service you will be billed later, generally
within 30 to 60 days.
As a patient and subscriber to a Health Insurance Plan, it is important
you understand
the healthcare provider’s relationship is with you and not your
insurance company.
It is your responsibility to be aware of your insurance coverage,
policy provisions, exclusions and limitations as well as preauthorization
requirements. This information is furnished by the insurance carrier.
If your coverage is not in effect at the time of your visit,
the financial responsibility for payment is yours.
If there are any changes in your insurance coverage, you must
notify us.
Deductibles are the patient’s responsibility.
The deductible is determined by the contract you have with your insurance
carrier. We do not know how much each person’s deductible is and how much
has been met at the time of your visit.
Co-payments and co-insurance are the patient’s
responsibility.
Unless specifically prohibited by our agreement with your carrier,
all patients are responsible for “non-covered” services if
denied by their insurance carrier.
It is your responsibility to obtain referrals if required to do so by your plan.
It is important that you respond to any request from your insurance carrier for additional information. Not doing so could result in a claim denial and you will be responsible for payment.
If insurance payments are sent to you, you are responsible for forwarding them to our office with a copy of the explanation of Benefits (EOB) received otherwise, the service will remain unpaid and could result in transfer to a collection agency for follow-up. Please forward payment as soon as possible to avoid any inconvenience.
There will be a $30.00 charge if your check is returned for non-payment by your bank.