Click here to see our Notice
of Privacy Practices (NPP)
take a moment to read the following policies which will be effective as of
January 2010. The following policies will allow us to provide timely,
courteous and reliable services to our patients.
At each visit, the
patient must provide an active insurance card with current, correct
information. Without proof of insurance, the patient may be re-scheduled.
Renaissance Health and Surgical Associates, P.C. makes it priority to
verify proof of a patientís insurance; however, it is the patientís
responsibility to know his/her insurance benefits including wellness
benefits prior to time of service.
Cost Co-Pays & Co-Insurance
If we are contracted
with your insurance company, we must follow our contract and their
requirements. If you have a co-pay or deductible, you must pay that at the
time of service. It is the insurance company that makes the final
determination of your eligibility. If your insurance company requires a
referral and/or preauthorization, you
are responsible for obtaining it. Failure to obtain the referral
and/or preauthorization may result in a lower payment from the insurance
company. You agree to pay any portion of the charges not covered by
Patients will be
asked to settle any outstanding balances with Renaissance Health and
Surgical Associates, P.C. before their appointment. As a patient, you may
pay any outstanding balances at our office, by mail or by phone. Patients
with outstanding balances may be declined treatment or exams for non
emergency care until the balance are resolved. Patient balances which are
not resolved in a timely manner will be sent to an outside collection
agency. If the patientís balance is transferred to an outside agency,
the patient will be responsible for paying any additional collection fees
associated with the collection of the patient balance.
and Surgical Associates, P.C. recognizes that not everyone has insurance
coverage. The initial office visit fee is $150.00, due at the time of
service. Although, it is difficult to accurately predict
what services a patient may ultimately need, Renaissance Health and
Surgical Associates, P.C. will try to work with the patients to help them
anticipate charges and mange their healthcare expenses.
If this or another
Financial Policy is signed by another person, that co-signature remains in
effect until canceled in writing. If written cancellation is received, it
becomes effective with any subsequent charges.
You give us
permission to check your credit and employment history and to answer
questions about your credit experience with us. We have the option to
report your account status to any credit reporting agency such as a credit
and Surgical Associates, P.C. contracts with most insurance companies for
patient services. The patient
remains financially responsible for all his/her care, but the remaining
balance for services rendered to the patient will not be billed to the
patient until payment is received from the insurance company(s), the
insurance company denies the claim, or the insurance company unreasonably
fails to pay in a timely manner. A Statement will be sent to the patient
or responsible party. The billed amount on the statement is due in full. A
late charge of $25.00 will be imposed on each account that is over thirty
(30) days past-due. We determine your account is past-due by taking the
balance owed thirty (30) days ago, and then subtracting any payments or
credits applied to the account during that time.
No-Show and Late
Patients who do not
show up on time for an appointment, or cancel appointments with less than
24 hours notice may be subject to a $25.00 fee, not for any service, but
for the lost opportunity to see another patient. This fee may be higher
for procedures other than routine office visits.
repetitive no show appointments may be discharged as a patient of this
and Surgical Associates, P.C. accepts cash, check, Visa or MasterCard.
There is a $25.00 fee for all returned checks.
Payment can be sent to:
Renaissance Health and Surgical Associates, P.C.
325 South Cedar Avenue, Ste 2
South Pittsburg, TN. 37380
If you have any
questions regarding our financial policies, please contact our Patient
Billing Services Representative @ (423) 837-5801.
Patient Accounts with
outstanding balances and no payment activity will be forwarded to a
collection agency at the patientís expense. In addition to any
outstanding balances, the Patient or the Patientís representative who
signs our financial policy agrees to pay all costs associated with such
collection activity, including reasonable collection agency fees, attorney
fees, and court costs.
Transferring of Records
You will need to
request in writing, and pay a reasonable copying fee if you want to have
copies of your records sent to another doctor or organization. The amount
of the fee is dependant upon the number of pages we need to copy. You
authorize us to include all relevant information, including your payment
history. If you are requesting records to be transferred from another
doctor or organization to us, you authorize us to receive all relevant
information, including your payment history.
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
bureau agency, the fact that you received treatment at our office may
become a matter of public record.