Financial Policy & Consent to Treat

Insured Patients: If you have insurance coverage, as a courtesy Prestige Medical Group (PMG) will file claims with your insurance company. In order to provide this service, we must have all current insurance information including a valid driver’s license or photo ID. Patients who do not provide the required information may be registered as self‑pay and payment in full may be expected at the time of service.

It is your responsibility to understand your insurance coverage and benefits. Patients are responsible for deductibles, copayments, coinsurance, and any services not covered by their insurance plan. Payment of patient responsibility balances is expected at the time of service unless prior arrangements have been made.

For your convenience we accept cash, credit cards, and debit cards. Personal checks are not accepted. Any balances assigned as patient responsibility that remain unpaid may be subject to collection activities after 90 days.

We are required by our contract with your insurer to collect your portion of the visit’s charges. It is your responsibility to pay any deductible, co-pay, or any other portion of the charge as specified by your plan.Any medical services not covered by the patient’s plan are the patient’s responsibility for paying the charges within 30 days of our statement if not collected at the time service was rendered. For your convenience we accept cash, money order, and all major credit / debit cards at our office. We do NOT accept personal checks. Any payments received may be applied to any unpaid bill(s) for which the patient is liable. Any and all balances assigned as patient responsibility may be subject to collection efforts after 90 days, as well as credit reporting.

Assignment of Benefits

I authorize payment of medical benefits directly to Prestige Medical Group for services rendered. I understand that I am financially responsible for charges not covered by insurance, including deductibles, copayments, and coinsurance.

Network Participation

PMG participates with many insurance plans; however, participation may vary by provider and location. It is the patient’s responsibility to verify that PMG and the treating provider are in‑network with their insurance plan prior to receiving services.

Missed Appointment / Late Cancellation Fee

We require at least 24 hours’ notice to cancel or reschedule an appointment.
Appointments that are missed or cancelled with less than 24 hours’ notice may be subject to a $50 missed appointment fee.

This fee is not billable to insurance and is the patient’s responsibility. Repeated missed appointments may result in restrictions on future scheduling.

Lab Testing:

Laboratory services are provided by Quest Diagnostics. They are not affiliated with PPC and there may be an additional charge if your insurance coverage does not include this lab. Please check with your insurance co. Any questions about billing from laboratories are to be resolved by contacting the lab company directly.

All Physicals:

Your provider may recommend that you have an annual physical. Each insurance plan has different benefits and each policy pays for physicals differently. It will be the patient’s responsibility to verify with his or her insurance company to see if and what is covered for an annual physicals. If the services are rendered and your insurance does not pay for the services then the patient will be responsible for the visit. When tests are ordered, the patient will be expected to return to the office to discuss results. Please note the follow up visit is not part of the PE and therefore your insurance does charge a copay or coinsurance.

Referrals:

If your plan requires a referral for diagnostic testing performed outside our office or a referral to another provider, the referral must be obtained prior to your appointment. We require 10 business days to obtain your referral authorization. Some plans may require these to be issued by your primary care physician. Once your appointment is scheduled and you have verified with your plan that referral is needed, call our office with the following information:

Date of appointment
Physician’s name or facility, their phone number and fax number
If it is a diagnostic test, we need the name of the test and location of the test.
Your insurance plan’s name and your identification number

Patient Authorizations:

I hereby give authorization to be treated as a patient at Prestige Primary Care and I authorize release of medical information necessary to pay the claim.

By my signature below, I herby authorize PPC and the physicians, and staff to release medical and other information acquired in the course of my exam/ treatment to the necessary insurance companies, third- party payors, or other physicians or healthcare entities required to participate in my care.

By my signature below, I hereby authorize assignment of financial benefits directly to PPC for services rendered under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment; I further understand that any balances not paid by my insurance within 90 days are the patients/my responsibility. I understand that account balances not paid within 90 days will be sent to collections and that I may be charged collection charges up to 40% and / or court costs and attorney fees.

I have read and understand this explanation of my responsibilities for services I receive from Prestige Primary Care providers:

Last Name

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Date

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Insured Patients: If you have insurance coverage, as a courtesy Prestige Primary Care (PPC) will file all claims directly with your insurance company. In order to provide this service for you, we must have all of your current insurance data. Insurance cards must be presented at each visit, a valid Driver’s License or photo ID, as well as the guarantor’s Social Security number are also required. Any patient that does not provide our office with the above mentioned data with be registered as Self Pay and payment in full will be expected at the time of service.

We are required by our contract with your insurer to collect your portion of the visit’s charges. It is your responsibility to pay any deductible, co-pay, or any other portion of the charge as specified by your plan. Any medical services not covered by the patient’s plan are the patient’s responsibility for paying the charges within 30 days of our statement if not collected at the time service was rendered. For your convenience we accept cash, money order, all major credit / debit cards at our office. We do NOT accept personal checks. Any payments received may be applied to any unpaid bill(s) for which the patient is liable. Any and all balances assigned as patient responsibility may be subject to collection efforts after 90 days, as well as credit reporting.

Assignment of Medicare, Medicaid Benefits, Third Party Insurance, Patient Certification, and Payment Request: You hereby certify that the information given by you in applying for payment under Title XVII and XIX of the Social Security Act is correct. You request that payment of these authorized benefits be made and assign the benefits payable for services rendered during this visit to the physician or organization furnishing the services. The undersigned if other than the patient and the patient are responsible for and agree to pay charges not covered by this assignment, including any Medicare deductibles.

PPC participates with most of the area insurance plans. However, if you have insurance that we do not participate in, though we still file the claim out of courtesy, payment in full is expected at the time of service. It is the patient’s responsibility to know if we are a network provider for their insurance before service is rendered.

Charges for Missed Appointments: We require 24 hours notice for the cancellation of any appointments. Failure to provide 24 hour notice for the cancellation will have the following charges: ❖Office Visit - $25 ❖Ultrasound, ECHO, Stress Tests - $50 ❖Any Type of Physical Exam - $50

Billable Service Charges: ❖Co-pay not paid at time of service $20 ❖Return Check $35 ❖Monthly Finance Fee 1.5% per month on balances over 30 days

Lab Testing: Laboratory services are provided by Quest Diagnostics. They are not affiliated with PPC and there may be an additional charge if your insurance coverage does not include this lab. Please check with your insurance co. Any questions about billing from laboratories are to be resolved by contacting the lab company directly.

All Physicals: Your provider may recommend that you have an annual physical. Each insurance plan has different benefits and each policy pays for physicals differently. It will be the patient’s responsibility to verify with his or her insurance company to see if and what is covered for an annual physicals. If the services are rendered and your insurance does not pay for the services then the patient will be responsible for the visit. When tests are ordered, the patient will be expected to return to the office to discuss results. Please note the follow up visit is not part of the PE and therefore your insurance does charge a copay or coinsurance.

Referrals: If your plan requires a referral for diagnostic testing performed outside our office or a referral to another provider, the referral must be obtained prior to your appointment. We require 10 business days to obtain your referral authorization. Some plans may require these to be issued by your primary care physician. Once your appointment is scheduled and you have verified with your plan that referral is needed, call our office with the following information: Date of appointment Physician’s name or facility, their phone number and fax number If it is a diagnostic test, we need the name of the test and location of the test. Your insurance plan’s name and your identification number

Patient Authorizations: I hereby give authorization to be treated as a patient at Prestige Primary Care and I authorize release of medical information necessary to pay the claim. By my signature below, I herby authorize PPC and the physicians, and staff to release medical and other information acquired in the course of my exam/ treatment to the necessary insurance companies, third- party payors, or other physicians or healthcare entities required to participate in my care. By my signature below, I hereby authorize assignment of financial benefits directly to PPC for services rendered under standard third-party contracts. I understand that I am financially responsible for charges not covered by this assignment; I further understand that any balances not paid by my insurance within 90 days are the patients/my responsibility. I understand that account balances not paid within 90 days will be sent to collections and that I may be charged collection charges up to 40% and / or court costs and attorney fees. I have read and understand this explanation of my responsibilities for services I receive from Prestige Primary Care providers:

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