Financial Policy - Midwest Vein Center

Financial Policy

Thank you for choosing Midwest Vein Center.

Please print and bring a signed copy with you on your initial office visit. Print

Midwest Vein Center Financial Policy

Thank you for choosing Midwest Vein Center (MIDWEST VEIN CENTER). We believe good care for you starts with good communication, and we have created this Financial Policy to help you understand the responsibilities for payments of our fees. If you have any questions, please contact our billing department at 630-322-9151.

The patient is always responsible for payment. In consideration of services to be rendered, you, as the undersigned patient or guarantor, agree to pay Midwest Vein Center for all services and supplies provided to you (or the patient) at the established rates, including any deductibles, co-payments, coinsurances, earlier charges that remain unpaid or any other charges as permitted by third party payors. By signing this financial policy summary, you accept responsibility for any costs, including attorney or collection fees incurred by MIDWEST VEIN CENTER for the collection of charges for examinations, diagnosis, or treatment received. Prior to services being rendered you must furnish MIDWEST VEIN CENTER with accurate insurance information. For your convenience we accept cash, checks, Care Credit, VISA, MasterCard, American Express and Discover.

Self Pay patients are required to pay for services at time of or prior to their visit or procedure.

Medicare—MIDWEST VEIN CENTER accepts Medicare assignment. For covered services, you are responsible for the deductibles and co-insurance amounts determined by Medicare. If you have supplemental insurance, we will bill the secondary carrier for you. If you do not have supplemental insurance the 20% coinsurance and/or any unmet deductible may be due at time of service. Once your claims are processed by Medicare, you will receive a statement for any outstanding patient responsibility. If MIDWEST VEIN CENTER believes because of your circumstances your care will not be covered by Medicare, an Advanced Beneficiary Notice will be presented to you and will be due at time of service.

Insurance—Please keep in mind, your insurance policy is a contract between you and your insurance company. You are ultimately responsible for all charges incurred. You must provide us with current and correct insurance information. You must notify MIDWEST VEIN CENTER immediately regarding any changes in insurance. All applicable copayments are due at time of service. If you are unable to pay copay at time of service, your appointment may be rescheduled. If you do not agree with the patient responsibility set by your insurance, this is a matter between you and your insurer. We are happy to provide you with factual information about your care and the billing to help you in your discussions. We will require you to pay the full amount presented even if your issue with your insurer is not resolved.

Pre-Estimates—Prior to services being rendered MIDWEST VEIN CENTER may conduct insurance verification and provide you with the estimated patient responsibility. MIDWEST VEIN CENTER may require you to pay some or all of the estimated patient responsibility prior to services being rendered. Because your insurance carrier can only provide MIDWEST VEIN CENTER with an estimation of patient responsibility, there may be an additional patient balance due once the claim processes. You will receive a statement for the additional balance due. If claim processing results in a credit balance on your account a refund will be processed.

Form Fees—Forms for workman’s comp, return to work releases, disability, etc. will be completed in a timely fashion, and will incur a “Form Fee”. The fee to complete such form(s) must be paid in advance and starts at $25 per form and increases depending on complexity of form. Form Fees will be assessed each time a form is completed. Except for obvious errors, forms will not be modified at the patient’s request.

Account Statements—Statements are mailed to patients monthly if they have an outstanding patient balance due on their account. Payment is expected upon receipt of statement. Any payment arrangement requires a signed agreement by the Midwest Vein Center or Care Credit. Accounts overdue may be referred to a collection agency.

No Show Fee—We understand there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. If an appointment is not cancelled at least two business days in advance you may be charged a $25 No Show Fee for an Office Visit or a $250 No Show Fee for a scheduled treatment. These fees will not be covered by your insurance company.

Non-Sufficient Funds (NSF)—Returned check fee $30. This fee will be increased if repeated.

Collections—In event of non-payment, the Doctor shall be entitled to the right of recovery for all collection expenses, including court costs and reasonable attorney fees, incurred for purpose of obtaining payment of the amount due. If your account is sent to a collections agency or we are listed in a bankruptcy suit you may be dismissed as a patient from our practice at your physician’s discretion.

Agreement

I have read the above policy and agree to it. I hereby authorize MIDWEST VEIN CENTER to provide me with health care services and to furnish information to any health insurance carrier, worker’s compensation carrier, or attorney concerning my treatment. I understand that I am financially responsible for payment of all co-payments, deductibles, co-insurance and non-covered services as determined by my insurance plan.
I authorize payment of my health insurance benefits to MIDWEST VEIN CENTER for all services provided.

I consent to be contacted by MIDWEST VEIN CENTER or anyone contacting me on its behalf for any and all purposes at any telephone number or physical or electronic address I have provided at which I may be reached, including any wireless telephone number. I agree that MIDWEST VEIN CENTER may contact me in any way, including calls or prerecorded or artificial voice or text messages delivered by an automatic telephone dialing system, or email or text messages delivered by an automatic emailing or messaging system unless I have indicated otherwise.

I acknowledge that this consent cannot be revoked without prior agreement and acceptance by both parties.

I agree to promptly notify the MIDWEST VEIN CENTER at any time my contact information or insurance information changes.

Please print the Midwest Vein Center Financial Policy and bring a signed copy with you on your initial office visit.
 

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