HMMG Financial Responsibility

Our physicians and Staff are dedicated to assisting you to make sure that your health insurance has all of the information necessary to reimburse for all covered services. Your health insurance may not pay for all your health care costs; you, your employer and your insurance company largely determine your health benefits. Health insurance only pays for covered items and services when their rules are met.

INSURANCE COVERAGE

  • It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions, and limitations as well as authorization requirements. This information is furnished by the insurance carrier.
  • We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of your visit, you will be responsible for payment.

INSURANCE CHANGES

  • If you have had any changes in your insurance coverage, please notify us. Failure to do so may result in a claim denial and you will be billed.

CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES

  • Co-insurance and co-payments are the patient’s/guarantor’s responsibility. Co­ payments are due at the time of the visit.
  • Deductibles are the patient’s/guarantor’s responsibility. The deductible is determined by the contract you have with your health insurance carrier.

REFERRALS

  • If your plan requires, it is your responsibility to obtain referrals from your Primary Physician prior to your visit. If you wish to be seen without the referral, payment is due at the time of visit.
  • If you require a referral to a Specialist Physician, please contact your Primary Physician at least one (1) business day before your appointment.

INSURANCE REQUESTS

  • You are responsible for responding to insurance company requests for further information.

INSURANCE PAYMENTS

  • Any insurance payments sent to you should be forwarded to our Billing Office with a copy of the explanation of benefits (EOB) received.

RETURNED CHECK/NON-SUFFICIENT FUNDS

  • A $25.00 fee will be assessed for any check returned for non-sufficient funds. 

CANCELLATION/NO SHOW

  • Cancel or reschedule your appointment at least 24 hours prior to your appointment. When a patient does not cancel or reschedule within 24 hours, a letter will be sent to the patient with an invoice for $25.00.

I have read and understand the terms of this Financial Responsibility form.