Welcome to Our Office
Please read this policy carefully and feel free to ask questions regarding any part of this form. We believe that a clear definition of our office and financial policies will allow us to concentrate on the primary goal of taking care of your health. Our practice will strive to provide you with the finest quality care. If you have any questions regarding your treatment, please do not hesitate to ask. We welcome referrals and look forward to establishing a satisfactory doctor-patient relationship.

If you are unable to keep an appointment please call the office to reschedule at least 72 hours in advance. Patients with two missed appointments will be charged a $15.00 no-show fee which is not reimbursable by any insurance. Patients with repeated missed appointments may be dismissed from the practice. Patients who are more than 15 minutes late may be asked to reschedule.

Transferring Records
Patient’s requesting copies of their records are asked to submit a request in writing to include all relevant information, including your payment history upon request. Please be aware that our policy is to provide records within 30-days from receipt of request. The fee for copying your records is $1.00 for this first 25 pages, and .25 cents for each additional page. If you are requesting your records to be transferred from another doctor or organization to us, you have to authorize us to receive all relevant information including your payment history.

Financial Policy
This is an agreement between West Coast Infectious Diseases, PA, a Florida corporation, as creditor and the patient/debtor named on this form. In this agreement the words “you”, “your”, and “yours” means the patient/debtor. The word “account” means the account that has been established in your name to which charges are made and payment credited. The words “we”, “us”, and “our” refer to the West Coast Infectious Diseases, PA. By executing this agreement you are agreeing to pay for all services rendered.

Completion of Forms/Medical Letters
There is a $20.00 fee for completing of each Form (including but not limited to, FMLA, disability forms, and handicap stickers), and Medical Letters relating to your condition. This fee is not reimbursable or billable to your insurance company, and must be paid by you before the form is completed. Please allow 7 to 10 days for completion of any form.

Insurance is a contract between you and your insurance company. (We are not a party to this contract, in most cases). We will bill your insurance company as a courtesy. We will accept secondary insurances, as long as it is medigapped (automatic crossover). Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance.

If your insurance company requires a referral and/or preauthorization/pre-certification you are responsible for obtaining it. We most likely will not be able to obtain a referral on the date of service, (and this will be at our discretion if time permits). Options at this point will be to reschedule the appointment or to pay at the time of service. We suggest you call your primary doctor at least 24 hours in advance to confirm that your referral has been generated and faxed. The most reliable method is to obtain it yourself.

Workers Compensation
We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury
If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility. We do not accept letters of protection and subsequently cannot bill your attorney for charges incurred due to a personal injury case.

Unless other arrangements are approved by us in writing, the balance on
your statement is due and payable when the statement is issued,
and is past due if not paid by the end of the month.

Required Payments
Any co-payment, deductibles or coinsurances, fees for non-covered services, or outstanding balances must be paid at the time of service.

Payment Options
You may choose to pay cash, check, or credit card on the day that the treatment is rendered.

Verification of Benefits
We may assist you, at our discretion, in verifying your insurance coverage in an effort to verify exactly what insurance coverage is available on your policy. This can only be done on the day of your appointment if time permits. You as the policyholder are primarily responsible to verify benefits and provide our office with the current insurance coverage information and any other information that has changed on your account for each visit. We cannot guarantee payment of the benefits and subsequently you may be responsible for any coinsurance, deductibles, or fees for non-covered services that may result.

Medicare Shared Savings Program
If applicable, please be aware they we do participate in a Medicare Shared Savings Program. Therefore, we may from time to time share medical data with our Accountable Care Organization. You have the right to opt out of this data sharing at any time by indicating below. By signing this form, you are authorizing us to share your medical data with our Accountable Care Organization and CMS as applicable under federal law.

Past Due Accounts
If your account becomes past due, we will take the necessary steps to collect this debt. If we have to refer your account to our collection attorneys, you agree to be responsible for all costs of collection, including a reasonable attorney fee, whether or not suit is filed. In case of a suit, you agree the venue shall be in Pinellas County, Florida. You expressly waive your right to jury trial.
I hereby declined to participate in Medicare Shared Savings Program and will not allow any of my medical data to be shared with any Accountable Care Organization.

Returned Checks
There is a fee (currently $25) for any checks returned by the bank.

Monthly Statement
If you have a balance on your account, we will send you a monthly statement. It will show separately the balance, any new charges to the account, and the finance charge, if any.

Waiver of Confidentiality
You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

If you have any questions or require clarification on this policy please ask to speak with our Billing Department or our Administrator (727) 669-6800.

Statement Clause
We reserve the right to interpret, change, suspend, cancel, or dispute with or without notice all or any part of our policy, and procedures, at any time without verbal or written notification.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise we urge you to contact us 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. West Coast Infectious Diseases complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.