Financial / Insurance Responsibilities
We will be glad to assist you in the pre-certification process with your insurance carrier, however, we cannot do it for you. You must actively participate in this process! Before your first visit you must check with our office to see which insurance companies we participate with. DO NOT RELY ON YOUR INSURANCE COMPANY FOR ACCURATE INFORMATION REGARDING THIS. We are in-network with only certain companies.
YOUR FINANCIAL RESPONSIBILITY WILL BE AS FOLLOWS:
Out of Network Insurance: |
In Network Insurance: |
Consultation Fee
(Due on your 1 st office visit) |
Co-Pay for Consultation
(Due on your 1 st office visit) |
Follow-Up Office Visit Charge
(Due at the time of the office visit) |
Follow-Up Office Visit Co-Pay
(Due at the time of the office visit) |
Pre-Surgery Payment
(Due 2 weeks prior to Surgery Date) |
Patient Deductible (if applicable)
(Due 2 weeks prior to Surgery Date) |
Surgical Fee
(Also included in this fee are follow-up visits/adjustments for 3 months post-op) |
Surgical Co-Pay
(Also included in this fee are follow-up visits /adjustments for 3 months post-op) |
Lap Band Adjustment Fee
(Due at the time of the adjustment) |
Lap Band Adjustment Co-Pay
(Due at the time of the adjustment) |
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It is your responsibility to contact your insurance carrier and find out what referrals, pre-authorizations, and pre-certifications are needed from this office or from your primary physician’s office. If any are needed and not obtained, you could be responsible for the full billed amount of the tests, procedures, and office visits.
We will submit your surgery and office visit claims to your insurance carrier as a courtesy to you for both in network and out of network policies. However, YOU are responsible for the charges not covered by insurance.
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