Hematology and Oncology Associates of Northern California is committed to providing the highest level of professional Medical care. For every commitment there is an obligation to provide quality care and service. Conversely, it is the Patients responsibility to meet their financial obligation.
This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided. You will be given a copy of this agreement for your records.
I have received this financial policy, and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts may be referred to a collection service. I also acknowledge that I have received a copy of this financial agreement for my records.
Insurance
Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.
Medicare
We participate in Medicare. You are responsible for your co-insurance, any deductibles that have not yet been met, and services that are identified as patient responsibility on your Medicare Explanation of Benefits. We strive to inform our Medicare patients of services that will not be covered. We may ask you to sign an Advanced Beneficiary Notice, which lists out fee and notifies you of your financial responsibility for certain medical services.
Managed Care
Many patients are enrolled in Managed HealthCare. In order for us to obtain referrals and/or pre-authorizations for procedures, it is important that we have your current information. Depending on individual policies, your procedure may not be a covered benefit. It is your responsibility to check for optimal covered and policy limitations, and to obtain referrals as required by your insurance company. Please contact your insurance company with questions regarding your coverage.
Patient Responsibility for Payment
You are responsible for payments of any co-payment, co-insurance, deductible or service not covered by your insurance, handing, collection or attorney fees. If you do not have insurance, you are responsible for payment of all services. Co-payments are due at the time of your service. Patient due balances noted on your monthly statement are due within 30 days of receipt. We will bill appropriate insurance if all required information is provided.
Deposits
New patients without insurance, or if insurance co-payment and coverage cannot be verified, are required to a deposit on or before the first date of service. If insurance payments results in a credit balance, it will be refunded to you within 30 days.
Payment Options
We understand that financial circumstances vary from patient to patient. If you are unable to pay your patient due balance in full, you must call our business office at 916-250-0166 to make payment arrangements. We offer uninsured patients a 10% discount for payment of office visit by cash, check, or credit card received on the date of service. Discount does not apply to lab or supply charges. Accounts with a patient due balance outstanding over 30 days will be charged a finance charge.
Non-Payment
Failure to pay will result in your account being referred to a collection agency, which may affect your credit. You must contact out collection analyst to discuss payment arrangements. If it becomes necessary to send my account to a collection service, I agree to pay for all costs and expenses, including reasonable attorney fees.