PAYMENT PRACTICES AND HIPAA

Payment Practices & Procedures

· Self-pay: Payment is due in full at the time of service unless arrangements have been made with the Digestive Healthcare Billing Office.

· Insurance: Our office will submit your insurance claim. Insurance companies rarely provide full coverage for endoscopic procedures; therefore, your co-pay is due at the time of service. Medical insurance is an agreement between the patient and insurance carrier—the patient, not the insurance company, is ultimately responsible for the payment to this office. If the patient is a minor, payment is due from the parent/guardian who accompanies the minor to the office. When payment is received from the insurance company, you will receive a statement for the balance or a prompt refund if a credit exists. 

· Social Security Number: Disclosure of your social security number is voluntary. However, failure to do so may require our office to have payment in full for services at the time they are rendered.

· PAyment for services for your conveniences, we accept cash, VISA, Mastercard, AMEX, debit cards, traveler's checks, money orders and personal checks. Started checks and postdated checks are not accepted. A valid picture ID is required on all checks. If copayments, coinsurances and/or deductibles are required by your insurance plan, they are due when services are rendered.

· Cancellation/No Show Policy To ensure that all our patients have access to our physicians, we have established the following fees for late cancellations and no shows.  Procedures cancelled less than 72 business hours of the appointment may be subject to a charge of $250.00. These charges will be billed to the patient and not their insurance carrier. P

Authorization for Treatment and Payment

By signing below, I consent to all medical and surgical procedures, laboratory tests, drugs, and treatments that the physician deems necessary for this visit at Summit Endoscopy Center, LLC. I assume responsibility for all charges I incur during the course of treatment. I understand that I will be billed for all non-covered services as permitted by my insurance.

Authorization for Release of Information

By signing below, I am authorizing Summit Endoscopy Center, LLC, to release any information concerning your treatment or visit to your insurance carrier, to the Healthcare Financing Administration or its intermediary carrier. Your report of care may also be released to other physicians involved with your care or physicians being consulted for your care. Payments of insurance benefits may be made to the party who accepts assignments. Regulations pertaining to the assignment of benefits apply.

Notice of Privacy Practices

The Privacy of Your Health Information Is Important to Us

We support your right to privacy of your health information. We are required by applicable federal and state law to maintain the privacy of your health information and to provide you with this notice about our privacy practices, our legal duties, and your rights concerning your health information. We reserve the right to make changes in our privacy practices for all health information we maintain. You may request a copy of our privacy notice at any time.

Your health information is used for planning of care and treatment, for communication among healthcare professionals involved in your care, for billing purposes, and for assuring quality of care.

By signing below, I acknowledge

1. I have been informed of Summit Endoscopy Center’s Privacy Practices and have been given time to review them and/or receive a copy. 

2. I understand Summit Endoscopy Center’s Payment Policy.

3. I have received verbal and written information concerning advance directives, patient’s rights, how to file a complaint or grievance and financial disclosure prior to my procedure.

4. I authorize my driver to be present in recovery when appropriate to receive verbal discharge instructions and procedure results or to receive a call with discharge instructions and procedure results.