We feel that everyone benefits when there is a definite and clear understanding of our financial policy prior to treatment.
This is an agreement between Women's Pelvic Surgery Center of Orlando, the office of Dr. Kathy Y. Jones, as creditor, and the Patient/Debtor named on this form.
In this agreement the words "you," "your," and "yours" mean the Patient/Debtor. The word account means the account that has been established in your name to which charges are made and payments are credited. The words "we," "us," and "our" refer to Women's Pelvic Surgery Center of Orlando.
By executing this agreement, you are agreeing to pay for all services that are received.
Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.
Payment options if you have no insurance:
- You may choose to pay by cash, check, or credit card on the day that treatment is rendered.
- On treatment involving surgical procedures you may choose to pay 50% on the preparation date and
the remaining balance within 60 days.
Payment options if you have insurance:
- You choose to pay any deductible, co-payment, or out-of-pocket portions at the time services are rendered by cash, check, or credit card.
- On treatment involving surgical procedures you may choose to pay any out-of-pocket expenses
on the preparation date by cash, check, or credit card.
Payments: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due by the end of the month.
Charges to account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.
Required payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these.
Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance 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.
Credit history: 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 to any credit reporting agency such as a credit bureau.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer you to a collection agency, you agree to pay the collections costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Orange County.
Collection fee: There is a $25 fee for any account that has to be turned over to a collection agency because of non-payment in addition to all of the conditions stated in the above paragraph.
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 reporting agency, the fact that you received treatment at our office may become a matter of public record.
Returned checks: There is a fee currently of $25 for any checks returned by the bank. Payment made on a returned check must be made in cash or by a money order.
Missed appointment fee: If you do not show up on time for an appointment, or cancel with less than 24 hours notice, there will be a missed appointment fee. The charge is $25 for a Maintenance or Re-evaluation appointment, and 10% of the total fee for surgery, urodynamics, cystoscopy, or any other procedure.
Copying of records: You will need to request in writing, and pay a reasonable copying fee ($1/page for the first 25 pages and 25 cents for every page thereafter) if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.
Form fee: There is a charge of $15 for any simple form and $25 or more for complex forms depending on the complexity.
Personal injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance other financial arrangements may be discussed. Payment of the bill remains the patient's responsibility. We cannot bill your attorney for charges due to a personal injury case.
Co-signature: If this or any other Financial Policy is signed by another person, that co-signature remains in effect until cancelled in writing. If written cancellation is received, it becomes effective with any subsequent charges.
Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.
Brochures and Urinary Cylinders: If these are needed your insurance will not pay for them. They must be paid for at the time services are rendered. The cost is $2.00 each.
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