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FINANCIAL 
RESPONSIBILITIES

— RACINÉE IS YOUR ABSOLUTE BEST OPTIONS, LETS TALK ABOUT IT.

Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.

 

FEES.

Our fees are determined by the complexity of each case and the different services used.  Read our Insurance Announcement

 

REGARDING INSURANCE.

We will verify coverage prior to treatment and we will file all claims as a courtesy to you. If for any reason we are not able to verify coverage prior to your treatment, you will be charged for the treatment until verification is obtained. We cannot bill your insurance unless you bring us all the necessary insurance information. We are not a party to that contract. By signing this document, you are assigning to this office the benefits to which you are eligible to receive for care rendered in this office. Additionally, in signing this document you authorize the release of any information to any insurance company, adjuster, or attorney that will assist in the payment of a claim. We request a credit card on file if the insurance company should not pay claims or any balances owed should there be any difference in the amount owed.
 

USUAL & CUSTOMARY RATES - UCR.

Unless canceled at least 24 hours in advance, our policy is to charge for a missed appointment at the rate of a normal office visit if you are a repeat offender of this rule. Your treatments will be more effective if you follow your physician's guidelines and stick to your treatment schedule. Please help us to serve you better by keeping your scheduled appointments. Please let us know if you have any questions or concerns. I have read the financial policy, and I agree with this financial policy. Could you work with me today?

 

MISSED APPOINTMENTS.

Unless canceled at least 24 hours in advance, our policy is to charge for a missed appointment at the rate of a normal office visit if you are a repeat offender of this rule. Your treatments will be more effective if you follow your practitioner's guidelines and stick to your treatment schedule. Please help us to serve you better by keeping your scheduled appointments. Please let us know if you have any questions or concerns. I have read the financial policy, and I agree with this financial policy. Work with me today!

 

BILLING OPTIONS.

OFFICE FINANCIAL POLICY AND AUTHORIZATION TO BILL INSURANCE:

There are two billing options available for you. Please select the one you prefer us to use for your visits. If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.

PRIVATE PAY

Private Pay patients are patients that do not bill insurance. This discounted cash rate is only applied to the published rate if you pay at the time of service.

 

BILLING

All co-payments and/or co-insurances not covered by your insurance company at the time of check-in, and every visit thereafter. RHWC will submit your claim for you to your insurance company. Although RHWC verifies your insurance; understand that this verification is not a guarantee of payment. Understand that any and all charges incurred at this office including co-payment, co-insurance, percentage due and/or deductibles, or any other fees or services not covered by my insurance company are your responsibility. Understand that if these clients' portions due are not paid at the time of service you will be subject to a $10.00 billing fee per month – no exceptions until the outstanding amounts are paid. Furthermore, understand that any unpaid balance over 90 days, can and will be sent to collections for recovery unless prior arrangements have been made.

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