FINANCIAL PAYMENT POLICY


Premier Heart & Vascular

Board Certified, Interventional Cardiology, Cardiovascular Disease & Nuclear Cardiology

Pranav Doshi DO   |   10240 W Indian School Rd Suie 140, Phoenix AZ 85037   |   Phone 602-922-1020


FINANCIAL PAYMENT POLICY

Thank you for choosing Premier Heart and Vascular. We are committed to providing our patients with the highest quality medical care. This financial policy is an important part of your health care. Due to increased insurance company demands, we ask you to read and agree to the following:

We make every attempt to accept a wide range of insurance plans. For the patient’s convenience we file medical claims with insurance plans with which we have an agreement, as long as the valid insurance information is provided to us. However, all policies have different benefits, and we cannot know the specific details of each individual policy. It is the patient’s responsibility to know their individual policy and to verify all benefits and coverage information prior to having any services rendered. Also, the patient is responsible for notifying us of any changes to his or her insurance plan or policy prior to the visit.

Co-pays and Deductibles: Insurance policies are an agreement between the patient and his or her insurance company. Contracting with health insurance companies requires us to collect co-pays and deductibles. The patient must pay this amount prior to seeing any of our healthcare providers

Additional Fees: If the patient does not have medical insurance or if Premier Heart and Vascular is not a contracting provider with his or her insurance carrier, all chargers incurred during treatment will be due and payable at time of service. A $35.00 charge will be applied to all checks returned. If a patient is unable to keep a scheduled appointment, we must be notified 48 hours in advance. Appointments cancelled after the time frame may be subject to a cancellation fee.

Appointment Type Fees
Office Visit $50.00
Surgery – Hospital procedure & Nuclear Testing $250.00

This fee will be your responsibility and must be paid in full prior to your next visit. Dismissal from our practice may result following 3 No Shows.

Any medical records request sent to someone other than a physician will be subject to a fee.

Timely Payment: If for any reason the patient incurs an account balance, we will mail a statement. Payment is due from the patient upon receipt of the first statement from our office. If the balance is not paid in full, Heart One Assoc reserves the right to send the patients account to collections and an additional 33% collection fee will be added. Please be aware that any delinquent account balance may prohibit the patient from scheduling future appointments.

Financial Hardship: Our Mission of providing twenty-first century cardiovascular science and technology with timeless compassion and care prompts us to provide care to our patients regardless of their ability to pay. This means that we will work collaboratively with patients who are under financial hardship to develop fair and reasonable payment plans. Financial hardship is determined by policy and is a formal process that must be a joint effort between our financial counselor and the patient. The patient will be asked to provide documentation and a full explanation of extenuating circumstances regarding their hardship. Extenuating and/or special circumstances will not include patients that have overextended themselves financially. A patient who has the ability to pay and has not been formally determined to be in a financial hardship is expected to pay at the time of service and maintain no outstanding balance.

We find that communication with our patients regarding our financial policy assists us in providing the best service to you. We have therefore taken the time to answer some of the

Most commonly asked questions. How may I pay? We accept payment by cash, check, VISA, MasterCard, Discover, and American Express.

What is my financial responsibility for services?

Your financial responsibility depends on a variety of factors, explained below:

If you have ........... You are responsible for ...... Our staff will ............
Commercial Insurance
Medicare
Medicare Replacement		 Payment of the patient responsibility for all office visits, injections, office procedures and other charges at the time of office visit. File an insurance claim as a courtesy to you.
HMO & PPO plans with which we have a contract

HMO with which we are not contracted and are not applying for		 If the service’s, you receive are covered by the plan:
All applicable copays and deductibles are requested at the time of visit

If the service’s, you receive are not covered by the plan: Payment in full is requested at time of visit.

Payment in full for office visits, injections, office procedures and other charges at the time of visit.		 File an insurance claim on your behalf.
Provide the necessary information for you to complete and file your claim directly with the insurance company.
Point of Service Plan or Out of Network PPO Payment of the patient responsibility – deductible, copay, non-covered services-at the time of the visit. File an insurance claim on your behalf.

No Insurance: Payment in full required at the time of service.

I have read and understand the Premier Heart and Vascular financial policy. I authorize Premier Heart and Vascular to obtain and/or release medical information necessary for filing insurance claims on my behalf and for the purposes of healthcare management. I assign all benefits to which the patient or insured is entitled for my treatment and medical services provided to me to be paid directly to Premier Heart and Vascular. Should insurance payment be made directly to the insured, I agree to immediately pay these funds to Premier Heart and Vascular.

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