Office Policy - Please Read Carefully
We are providers for several PPO and HMO insurance plans and will be happy to file your claim for you. Co-payments are due prior to seeing the physician at the time of service. You are responsible for obtaining any necessary referral or authorization from your primary care physician. You are responsible for any non-covered charges. If you’re insurance does not make payment within 45 days, you may be asked to call them for the status of the claim.
Frequently, insurance companies may require additional information from the patient before processing a claim. If you receive such information in the mail, please fill out the form and mail it back to your insurance company as quick as possible. Failure to do so will make you responsible for the entire bill regardless of our contract status. We will expect payment of the deductible and coinsurance amounts at the time of service, or proof that your deductible has been met. We allow 60 days for processing of your insurance claims. At the end of that time, if your insurance has not paid, the entire balance becomes your responsibility.
Houston Nephrology Group, P.A. accepts assignment for our Medicare patients. We will file with Medicare on your behalf but co-payment is expected at the time of service which is 20% of the Medicare allowable. If your deductible is not met we Will collect in full for services rendered.
Houston Nephrology Group, P.A. will file claims to Medicaid on your behalf. You must present a current copy of your Medicaid card at each visit.
No show Policy
Houston Nephrology Group, P.A. implements a NO SHOW policy. If a patient does not cancel or reschedule their appointment within 24 hours of the appointment date a $25.00 charge will be added to their account.
Notice of Privacy Practices
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
If your account is over 120 days old (4 months) and there has not been any effort to pay the balance, the account will be reported as a bad debt to the Credit Bureau.
Please sign below that you have read this office policy and agree to it. If there is a problem, please speak to the Office Manager before seeing the doctor.
Print Name: ____________________________________ Date: _____________________
Signature: _____________________________________ (Sign & date in person at our office)