If your insurance requires a referral, it is your responsibility to make sure that your doctor has sent the referral prior to your appointment, or you will be responsible for the cost of you appointment at the time of service.
If we do not participate with your insurance, we require payment on services rendered. All claims will be submitted to you insurance company for you. You will be responsible for the unpaid balance. We will be happy to appeal the claim ONCE. If denied we will give you any information you need to appeal the claim upon request.
Medicare patients that do not have a secondary insurance to cover copayments, coinsurances or Medicare’s yearly deductible, will be required to pay 20% of the charges for the visit and/or office procedures.
Workers’ Compensation and No Fault patients must have insurance information so that we can submit all of the necessary paperwork. It is your responsibility to supply us with all the correct information, including the insurance company, claim number, accident date, and a contact name and number. Failure to give us the information in a timely manner (45 days) will result in the patient being billed the full amount of services rendered. Motorcycle accidents are not covered by No Fault.
If you are victim of a crime and you have insurance, your health insurance is primary. Be sure you report the crime to the police. You may be able to obtain assistant from the New York State Crime Victim's Board. Please ask if you would like more information on Crime Victims.
Cosmetic surgical fees will be discussed with you at the time of your visit.
If we are required to take legal action to collect payment, you will be responsible for any and all fees associated with such action, including filing fees, attorney's fees and collections fees.
Please let us know if you have any questions or would like a copy of this form for your records. Thank you.