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Financial
Policy
Financial Policy
 
Basic Policy:Payment is due in full at the time service for self pay patients.
Participating insurance:We will bill your insurance carrier directly.  We require a copy of your insurance card to obtain the proper information.  All co-payments and deductibles are due at the time of service.  Please call our billing department at 315-786-8700 to verify participation with your insurance.
Medicare Patients:We will bill Medicare for you. We will also bill your secondary insurance carrier for you. All co-payments and deductibles are due and payable at time of service.
Medicaid Patients:You must provide a current and valid Medicaid card when you check-in for each visit. If your Medicaid card is invalid for any reason, payment will be due by you at the time of service.
Non-covered Services:Any care not covered by your insurance carrier will require payment in full at the time services are provided or upon notice of insurance claim denial.
Workers Compensation/No Fault:If your injury is work or auto related, we require the proper insurance carrier's name, address and phone number at the time of service. We will also need policy and case numbers to complete claim forms.
Annual physicals etc:Annual physicals, work, school and other preventive health care services may or may not be covered under your health insurance policy.  You will need to check with your insurance carrier prior to your appointment to determine coverage. To insure proper billing please inform your healthcare provider at the time of service if you expect your insurance to cover any of the above services.  We will not change our billing AFTER the fact.  Any non-covered services are due at the time service is provided. 
Missed Appointments:In fairness to other patients and our health care providers, we require at least 24 hours' notice to cancel appointments.
 
Medicare Patients Signature on file:I request payment of authorized Medicare benefits to be made to Watertown Internists for any services furnished by Watertown Internists. I hereby give my consent for Watertown Internists to use and disclose Protected Health Information (written or electronic) about me to carry out treatment, payment and healthcare operations (TPO) to CMS (Center for Medicare & Medicaid Services) and its agents, any information needed to determine benefits or benefits payable to related services. I understand my signature requests that payment be made and authorizes release of any PHI necessary to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of PHI to the insurer or agency. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare Carrier.
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***
 
 Insurance Assignment:I hereby assign all medical benefits, to include major medical benefits to which I am entitled from private insurance and/or any other health plans including Medigap or Medicare secondary polices, to Watertown Internists. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand I am financially responsible for all charges whether or not paid by said insurance. I hereby give my consent for Watertown Internists to use and disclose any necessary PHI about me to carry out treatment, payment and healthcare operations (TPO).
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***
 
General Consent For Treatment:
*I hereby request, consent, and authorize the healthcare providers of Watertown internists, P.C. to administer and perform all medical treatments as he/she feels is medically necessary. This includes general & preventative medical care, medical examinations, diagnostic procedures, laboratory tests and cultures, prescribed medications, arrange referrals and administer immunizations.
*I understand that certain medical conditions may require photographic documentation and hereby consent to medically necessary photographs of any procedures or conditions.
*I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of any procedure, treatment or examination.  
*This consent shall remain effective until I revoke it in writing, which I may do at any time, except to the extent that the healthcare providers of the practice have acted in reliance upon this authorization.
***SIGNATURE OF PATIENT ON FILE VIA EMR (ELECTRONIC MEDICAL RECORDS) ***

3/03 form date edited 3/05, 9/10,4/14

 
 
 
 

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