Thank you for choosing to receive your health care at our medical office. This document contains important information about your financial responsibility for services you receive. We want you to be informed about the costs of care and your obligations. Please be sure to contact our office and ask any questions you may have.
TO AVOID ERRORS AND TO HELP US SERVE YOU BETTER
PLEASE BE SURE TO PRESENT YOUR INSURANCE CARD AT EVERY VISIT
You are responsible for payment of any co-payment, deductable, or coinsurance required by your insurance plan. If your insurance company denies or delays payment, we will bill you directly. If you do not have medical insurance, you are expected to pay for all services at the time of your visit. We accept MasterCard, Visa and Discover Card. We also accept personal checks. If you pay by check and your check is returned, it will be necessary to charge a $15 handling fee to cover our costs with the banks.
Co-payments, co-insurances, known deductable amounts and all other balances on your account are due at the time of your visit. If absolutely necessary, we can make arrangements for a reasonable payment plan over a short term period of time. Please contact our Billing Department.
In situations where a custodial for divorce/separation agreement calls for "split responsibility" for payment for medical services, we bill the full amount due to that person presenting for the services. If that person is a child, the parent/guardian bringing the child is expected to pay for services.
You insurance plan may require that prior authorization be obtained for certain services. Please contact you insurance company to see if there are any referral requirements before receiving services from us. If it's required, you are responsible for obtaining the referral from your plan or primary care physician. Please remember that a referral is not a guarantee of coverage by your health plan.
All insurance companies have limits on the services they cover and it is extremely important that you know your membership eligibility, benefits, limitations and exclusions under your specific plan. If we do not participate with your insurance plan we will submit a bill to your carrier as a courtesy. However the financial obligation remains your responsibility. If we bill your insurance and payment is denied for any reason, payment remains your responsibility.
Where to Go if You Have Questions
Our Billing Staff is available to help you if you have any questions regarding our policies or your account. To reach a Billing staff member, please call (866) 431-4077, Monday-Friday, 8:00am-4:40pm.
I authorize payment of medical benefits to Valley Medical Group, P.C. for services received (including government benefits). I consent to and authorize Valley Medical Group, P.C. to use and disclose any of my health information, including my medical records, for purposes concerning payment for health care services provided to me.
FOR QUESTIONS REGARDING YOUR INSURANCE POLICY AND HEALTH PLAN, PLEASE CALL THE TELEPHONE NUMBER ON YOU INSURANCE/ID CARD
Click here to download this page in PDF format (Adobe Acrobat is a free download).