SURGICAL ASSOCIATES OF THE MID-CITIES recognizes the need for a clear understanding between patient and surgeon regarding payment for surgical care. The following information is provided to avoid any misunderstanding concerning payment for professional services:
• Payment: If your deductible or out of pocket expense that is your responsibility has not been met, we expect payment when services are rendered. You are exempt from this policy if your primary insurance carrier is Medicare or a managed care insurance that requires only a co-payment at the time of service. EVEN THOUGH INSURANCE WILL BE FILED, YOU ARE RESPONSIBLE FOR ANY BALANCE AFTER INSURANCE PAYMENTS HAVE BEEN MADE. All charges for treatment become due and payable WITHIN ninety (90) days after date of service. This period allows you time to make payment in full of any remaining balance.
• Nurse/Surgical Assistant Fees: Your surgeon may have this nurse, or one of his partners in the operating room, acting as a first assistant. The first assistant’s presence helps your operation proceed in a safe and responsible manner. Your insurance will be billed for the assistant’s service and you may be financially responsible for a portion of the assistant’s charges after the insurance company has paid your allowable.
• Self-payment (private, cash payments): If you have no insurance coverage, we ask that you coordinate your care with our business office prior to your surgery. We require an advance payment for professional services.
• Managed Care: All Managed Care co-payment amounts are due to at the time of service
• Medicare: We are participating providers with the Medicare program and accept as payment. If you have secondary insurance to cover the 20% portion of charges, please provide us with a copy of both insurance cards.
• Children of divorced parents: Responsibility of payment for treatment of minor children, whose parents are divorced, rests with the parent who seeks the treatment. Any court ordered responsibility judgement must be determined between the individual involved, without the inclusion of Surgical Associates of the Mid-Cities.
• IT IS YOUR RESPONSIBILITY TO ENSURE THAT THE PHYSICIAN YOU ARE SEEING IS PART YOUR INSURANCE NETWORK. It is also required that you OBTAIN AND HAVE AT THE TIME OF YOUR VISIT ANY REFERRAL REQUIERED BY YOUR PLAN. Failure to obtain this referral may deem your medical treatment as “Out of Network” by your insurance company and you will be responsible for a larger amount of the charges. We will obtain pre-certifications required for your office procedure and surgeries.
• Collections: I understand that I am financially and legally responsible for all charges. I further agree that should I not pay the balance within ninety (90) days after date of service my account will be turned over for collections and will be responsible for all costs, collection agency fees and interest, which shall accrue at the maximum rate allowed by law.
• General Consent for Treatment: I consent to and authorize Surgical Associates of the Mid-Cities to treat any condition that I might have and seek to have treated.