Appointment and Financial Policy
Originally effective: 12/1/2020
Thank you for choosing us for your Allergy and Immunology healthcare needs. We are committed to providing you with the best medical care. The following is a statement of our appointment and financial policies which we require you to read and sign prior to your treatment.
It is your responsibility to provide us with accurate information so that we can file your claims correctly, including copies of your insurance card(s) and photo identification. If your address, telephone number, or insurance changes, please notify us immediately. If your insurance changes it is your responsibility to verify that we are contracted with your new plan.
Referrals and Authorizations:
Some insurance plans require your primary care provider to obtain a referral authorization number from the insurance company in order for you to see us. A referral requirement is the result of your contract with your insurance company, so it is ultimately your responsibility to ensure that it has been done prior to your visit. If your insurance company denies payment because a referral has not been obtained, you will be responsible for the cost of the visit. You are responsible for any balances classified as ‘Patient Responsibility’ by your insurance company. Any dispute with claim processing is between you and your insurance company.
We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.
Financial Arrangements for Payment and Fees:
Once your insurance processes your claim, a copy of the EOB (Explanation of Benefits) will be issued to you by your insurance company. We will send a statement for balance due based off of your finalized claim. Because we realize that every person’s financial situation is different, we provide a variety of payment options. For your convenience, you may pay in person or by mail, or allow the balance to be charged to your credit card on file. We accept all major credit cards, debit cards, personal checks and cash for payment. Credit cards on file will be used to pay copayments which are due on the date of service, and any remaining balance owed by you 30 days after your insurance processes your claim.
If payments are declined or a credit card is expired at the time of payment, we will call you. If the reminder call is not returned within one week, a $35 collection fee will be applied to your account. Returned checks will be subject to a $35 returned check fee. If the check is returned for any reason, you will have 7 days to contact our office and arrange another form of payment. All accounts over 60 days without an approved payment plan are subject to a finance charge of 15% APR. Past due account balances must be settled before being seen for subsequent appointments, and future appointments may not be scheduled until a valid and currently valid credit card is on file.
We gladly reserve appointment times for you and appreciate that you have chosen Kaufman Allergy Asthma and Immunology for your care. As a courtesy, we will remind you of your appointment by calling and/or text/emailing you prior to your scheduled date and time. If we cannot speak to you directly, we will leave a message for you. However, in the event your mailbox is full or your line is busy, our efforts to contact you may be unsuccessful.
An appointment is a contract of time reserved for your treatment. We respect our patients’ valuable time and we request the same courtesy from our patients. Please extend this courtesy should you need to cancel and/or reschedule your appointment.
We reserve the right to charge $75 for regular appointments cancelled or missed without advance notice of 2 business days prior to the appointment We charge a $150 fee for cancelled or missed appointments for allergy testing or food or drug challenge without providing us notice 3 business days prior to the appointment.
If you arrive to your appointment late, we will do our best to work you back into the schedule; however, you may be asked to wait or to reschedule.
Due to the tremendous volume of patient forms requested on a regular basis, we kindly request that required forms or unscripted letters for school or work (ie. Action Plans for Food Allergy, Asthma, Medication forms for school, etc.) are completed during your medical appointment. There is no charge for these required forms if completed during a visit.
If forms or unscripted letters required for school or work are requested to be completed at a time not concurrent with a visit, we reserve the right to charge $25 for their completion.
For completion of forms that are of much greater length and take considerable time of medical records review (i.e., Disability forms, FMLA requests, EFMP requests, etc.), we reserve the right to charge $50 for their completion.
Patient Parent or Guardian Responsibility:
The parent or guardian who accompanies a child to their Allergy Immunology appointment has authorization to consent to medical care as needed and is responsible for payment of medical services. It is the parent or guardian’s responsibility for payment of all Allergy Immunology services provided by Kaufman Allergy Asthma and Immunology, PLLC in accordance with the practice’s fees and terms. In the cases where a parenting plan exists, the parent that brings the child in for the appointment is considered the guarantor and is responsible for payment.
All children under the age of 18 years must be accompanied by a parent or guardian to all visits where testing will be performed or for allergen immunotherapy (allergy shots). At the initial visit, a parent or guardian may sign our consent allowing us to render care to their children under the age of 18 years for follow up visits only without the presence of a parent or guardian.
Assignment and Release:
I authorize payment to be made directly to Kaufman Allergy Asthma and Immunology, PLLC by my insurance company, and I accept financial responsibility for all services not covered by my insurance. Copayments, deductibles, coinsurances and self-pay payments are due at the time of service and no exceptions will be made. I authorize release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.
Credit Card on File Policy:
Kaufman Allergy Asthma and Immunology, PLLC is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. You will be asked to provide or verify your credit card number at the time you check in for your visit. Your credit card will be scanned with a card reader. Your credit card number will be stored in a secure, compliant location in your electronic medical record. For security reasons only the last four digits will be visible to our staff. Credit cards on file will be used to pay copayments which are due on the date you are seen in our office, and any remaining balance owed by you 30 days after your insurance processes your claim.
If payments are declined or a credit card is expired at the time of payment, we will call you. If the reminder call is not returned within one week, a $35 declined payment fee will be applied. Additional appointments will not be scheduled until a valid and currently valid credit card is on file.
I give Kaufman Allergy Asthma and Immunology, PLLC permission to charge my credit card for any patient balance due on my account, including fees noted in this document (inclusive of late cancellation, missed appointments, returned checks, declined credit card payment, fees for forms, or finance charges). If I have insurance coverage, my card will be charged AFTER my insurance has paid their portion.
Acknowledgement of Financial Policy:
I have read a copy of Appointment and Financial Policy provided by Kaufman Allergy Asthma and Immunology, PLLC, and I agree to abide by these policies.
Name of Patient (printed) Date
Signature of Responsible Party (Guarantor
Note: The patient (or guarantor) must sign this sheet and present valid photo identification before the patient can be seen. This is for your protection and to prevent fraud.