ACKNOWLEDGEMENT OF OFFICE FINANCIAL POLICY
It is the patient’s responsibility to provide us with the most current insurance and billing information to avoid any denial of claims. This includes but is not limited to new insurance policies, referrals from the patient’s PCP (if required) insurance, insurance policy changes, new identification cards, etc.
If the claim has been denied, the patient will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship is with the patient, and not the patient’s insurance company. It is the patient’s responsibility to know and understand the coverage for the level of services under the patient’s insurance plan. We encourage all patients to contact their insurance companies, Employers, or Benefits Coordinators before services have been rendered to understand proper coverage.
The office of Dr. Vivian Asamoah utilizes the services of Right Medical Billing for billing services. For questions pertaining to statements, claims, balances, and all other billing matters, please contact them directly at 832-705-7838
ADMINISTRATIVE POLICY AND FEES
Medical Records can be faxed to another physician’s office at no charge with a valid signed consent to release.
Requests for hard copies of Medical Records are subject to a $25 Administrative Fee.
Administrative forms that need to be completed by the physician (FMLA, Disability Forms, etc) are subject to a $25 administrative fee.
THIRD PARTY BILLING
The providers may find it medically necessary to recommend diagnostic tests from third party sources who may submit claims to the patient’s insurance. If diagnostic services such as labs, imaging, and specialty testing, are ordered by the providers, it is the patient’s responsibility to verify network coverage and benefits with their insurance. Please be advised that our office does not obtain insurance verifications or submit claims to the patient’s insurance for third party diagnostic services.
MEDICAL RECORDS REQUESTS, FMLA, DISABILITY FORMS
-Medical Records can be faxed to another physician’s office at no charge with a valid signed consent to release.
-Requests for hard copies of Medical Records are subject to a $25 Administrative Fee.
-New FMLA or Disability submissions: These require an office visit to evaluate the patient's necessity and work limitations. This visit can be done by telephone and the patient’s copay will be charged along with a $40 administrative fee.
-Renewing FMLA or Disability Forms: Patients will be charged a $40 administrative fee payable in advance.
CANCELLATION POLICY AND FEES
Our office makes several attempts to remind patients of their appointments via phone calls, text, and email to confirm appointments in advance. The cancellation policy is as follows:
- Office Visit Copays MUST be paid 48 hours in advance of the scheduled appointment, or the appointment WILL be canceled. Links for payment are provided with confirmation messages. Payment can also be made over the phone during office hours.
-Appointments MUST be confirmed at least 48 hours in advance. Unconfirmed appointments WILL be canceled.
-Failure to notify the office of a cancellation ( “No Show”) to the appointment, will result in a $25 fee.
-There is a $25 fee for the cancellation or rescheduling of an office appointment without a 24 hours notice.
-There is a $100 fee for the cancellation or rescheduling of a procedure, less than 24 hours notice.
-Failure to notify the office of a cancellation (“No Show”) of IV Infusion appointment or cancellation less than 24 hours prior to the appointment, will result in a $100 fee due to personalized IV bag preparation.
-All fees will be collected prior to rescheduling the appointment.
I acknowledge that I have read and understand the financial policy of this medical office. I also understand and acknowledge that such terms may be amended by the practice without prior or written notice.