The doctors and staff at The Pelvic Floor Institute would like to welcome you to our Practice. We strive to provide you with excellent medical care and our goal is to make your visits as convenient as possible.
Please be advised that:
- It is your responsibility to inform our office of any address or telephone number changes.
- Your account is to be kept current—accordingly, all self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service. Payable by cash, check, Visa, MasterCard, Discover or American Express.
- If you do not have your payment(s), your appointment may be rescheduled. You may be asked to schedule another appointment for issues other than the reason for your original appointment.
- A returned check will result in a $25 service charge and all future payments being required in the form of cash or credit card. You will only be sent a statement if your balance exceeds $5 and you will only receive a refund if the credit amount is over $10.
- Refunds will be issued within 4-6 weeks from the date requested, if there are no pending insurance claims.
- There is a $50 charge for the completion of paperwork (ex: disability, FMLA, etc.)
- Any unpaid balances older than 30 days may be subject to 1.5% interest per month.
- If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 35% of your outstanding balance, court costs and attorney fees.
If you have health insurance coverage:
- We will submit your claims, however we must emphasize that as medical providers, our relationship is with you, not your insurance company. Although we attempt to verify your benefits with your insurance policy, please be advised this is only an estimate of your coverage based on the information given to us at the time of the inquiry.
Please be advised that:
- It is ultimately your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment.
- It is your responsibility to have a referral faxed to our office prior to your appointment because as a specialist, we require a referral requested from the insurance.
- Not all services are a covered benefit with all insurance plans.
- It is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit under your insurance policy.
- You are responsible for any non-covered charges not payable by your insurance policy.
- Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us. We are here to help you.