Fillable Printable Sample Patient Payment Policy
Fillable Printable Sample Patient Payment Policy
Sample Patient Payment Policy
___________________ID
Catalyst Medical Center
Patient Payment Policy
Effective 4/1/2009 Page 1 of 2
Catalyst Medical Center strives to ensure a clear understanding ofyour financial responsibility with respect to
the medical services we provide. These policies apply to all procedures and departments.
Co-Pays: We require payment of co-paysat the time of service, and reserve the right to refuse treatment.
No Insurance:Ifyou have no insurance,wecollect $150 for your initial office visit, $75 on your follow-up
visit. (Note: there may be additional chargesto your office visit if scopes or procedures are required.) We
collect a partial payment on elective procedures at the time of service. A representative will contact you
before your elective procedure to arrange payment in full or to set up a payment plan.
Payments:We accept cash, Visa, MasterCard, Discover and CareCredit. We also accept payment by
checkand debit cards. Weholda credit card number on fileto reserve an appointment. Catalyst Medical
Center will send patients accounts to collections for balances not paid after receipt oftwo statementsunless
you make payment arrangements with our billing office. We reserve the right to require payment for services
to be made at or before the time of service.
Allergy patient payments:SeeCatalyst Medical Center’s waiver form for Sublingual Drops.
Outstandingbalances:We may refuse to see patients with balances over $250, and who are not making
regular payments on the balance. If you have an unpaid balance at the end of abilling cycle, we applya $5
late payment fee to your account. If you makea payment and it is insufficient to pay both the late payment
charge and the principle amount due, we apply your payment to the late payment fee due and then we apply
the remaining amount to the principal. In the event that your accountis placed for collection, a collection fee
will be added to your account, along with any attorneyfees and/ or court costs that maybe necessaryfor
recovery of theoutstanding balance. In the event of an NSF check, there will be a$30 NSF charge added to
the balance due.
Cancellations: We charge your credit card on file if you do not call and cancel your appointmentwithin the
timeframes below. Notification allows the doctor to see another patient who needs to be cared for that day.
Regular appointments: We charge $25to your credit card if you do not call and cancel your appointment
24 hours ahead of time for all regular scheduled appointments.
Allergy testing appointments: We charge $150 to your credit card if you do not call and cancel your
appointment 48 hours ahead of time.
Cosmetic/Skincare appointments:We charge the full amount of service (up to a $150 maximum) to your
credit card if you do not call and cancel your appointment 24 hours ahead oftime. Payment is due for
cosmetic and skincare at the time of service.
Cosmetic and self-pay deposits and payments:Werequire a $500.00 nonrefundable deposit due at the
time the surgeryis scheduled. We requirepayment for self-pay procedures oneweek before the surgery is
performed.
Claim Filing:We happilyfile your claim with your insurance company as a courtesy. Please keep in mind
that payment remains your responsibility. We do not enter disputes over insurance benefits. We bill
insurance inaccordance with all federal, state and other contractual requirements in cases where we have
an agreement or we are a participating provider. We expect payment in full from you ifyourinsurance
companydelays processing of your claimfor over 60 days. You agree to payany portion of the charges not
covered byinsurance. Ifyour insurance companysends payments directlyto you, send or drop-off the
payment to Catalyst Medical Center, and we will apply it to your account.
___________________ID
Catalyst Medical Center
Patient Payment Policy
Effective 4/1/2009 Page 2 of 2
Medicaid:We file Medicaid patient’s claimsfor the states of North Dakota and Minnesota. Ifyou have
assistance fromanotherstate, you will beresponsible for payment ofthe services you receive andthe filing
of your own claims. It is the Medicaid patient’s responsibility to receive referral.
Workers Compensation: If your claim is denied you will be responsible for payment in full.
Preauthorization:Most insurance companies require preauthorization before you have a surgical
procedure. Failure to obtain preauthorization mayresult in your insurance companyrefusing to pay your
claim. Any refusal of payment by insurance for this reason is your responsibility.
Dependants: You are responsible for payment ofservices rendered to your dependents on your account. In
cases where a written court order allows payment for medical costs associated with a dependent, it is the
responsibility of you to obtain reimbursement from the other party involved.
Referrals: Ifyou see a doctor that is out of network or if you use an insurancecompany thatrequires a
referral, you are responsible for obtaining itfrom your primary care clinic or physician. Failure to obtain it may
result in a lower payment or no payment from the insurance company or no benefits fromyour insurance
company and you will be responsible for payment.
Surgery:Upon request, the SurgeryCoordinator will explain a cost estimate, which shows your financial
responsibility, based on the benefit levels and coverage of your insurance plan.The amount ofwhich
depends on your coverage and deductible amount.
Forms/Letters/Medical Records:We maybill $25 for forms or letters that a provider completes on your
behalf. We charge $25 copy fee for medical records requested for personal use.
I authorize Catalyst Medical Center to keep my signature on file and to charge my credit card (held
in our secure system) for:
1.Charges associated with appointments that are not cancelled within the timeframes listed above.
2.Charges associated with payment arrangements. Contact billing office to make payment
arrangements.
Attestation Statement:
I have read, understand, and agree tothe above Catalyst MedicalCenter Payment Policy. I
understand that charges not covered by my insurance company, as well as applicable copayments
and deductibles, are my responsibility. I acknowledge that these policies do not obligate Catalyst
Medical Center to extend credit.
I authorize my insurance benefits be paid directly to Catalyst Medical Center.
I authorize Catalyst Medical Center to releasepertinentmedical information to my insurance
company when requested, or to facilitate payment of a claim.
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Print Name of Patient
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Signature of Patient (or responsible party if minor) Date
