Download File - Star Care Inc

Star Care, Inc. Insurance Financial Policy
Thank you for choosing us as your health care provider. We are committed to your
treatment being successful. Please understand that payment of your bill is considered
part of our treatment. The following is a statement of our financial policy which we
require you to read and sign prior to any treatment.
WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD
Regarding Insurance:
Services rendered by Star Care, Inc. are your responsibility whether your insurance
company pays or not. Your insurance policy is a contract between you and your
insurance company. We are not party to that contract. Therefore, it is your
responsibility to know if we are an approved office for your plan. We do serve you by
calling your insurance company to verify coverage, but please be aware that this is a
verbal verification of benefits. Your insurance company determines benefits when
claims are sent in at which point coverage may deviate from the information that we
receive. Any balance that remains unpaid after 45 days may be applied to the charge
card number listed below and an invoice showing payment will be forwarded to you. If
you have any change in your insurance status or any other questions please contact us,
because communication is the most important tool to prevent misunderstanding or
collection action. By signing this form, the patient agrees to pay all costs of collections,
including attorney’s fees, if this account should become delinquent.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients and we charge
what is usual and customary for our area. You are responsible for payment regardless of
any insurance company’s arbitrary determination of usual and customary rates.
Missed Appointments
Unless canceled, at least 24 hours in advance, our policy is to charge for missed
appointments at the rate of $30.00. Please be aware that your insurance will not cover
these charges. Therefore, please help us serve you better by keeping scheduled
appointments.
I have read the Financial Policy. I understand and agree to this Financial Policy.
___________________________
Witness
________________________________
Patient’s Signature
Charge Card #_____________________exp_______
Date:________