Office Billing Policy

TRI-COUNTY MEDICAL CLINIC, P.C.

Insurance copayments will be collected on the date of service. If you are unable to pay your copayment at the time of service, arrangements must be made prior to your appointment. For your convenience, our office accepts personal checks, Visa, MasterCard, Discover and cash. Our returned check fee is $25.00.

Self pay (no insurance) patients must pay on the date of service.

All previous balances are due prior to your next appointment.

Due to many changes to insurance policies, it is no longer an easy task to interpret each individual policy. Although we try to stay on top of these changes, it is not always possible. It is your responsibility to know the special terms, deductibles, and/or copayments of your insurance coverage. Failure to notify us will result in non-covered expenses which will be your responsibility.

If you’re insurance requires you to have a written referral or authorization such as Workers Compensation or Auto Insurance it is the responsibility of the patient to obtain it PRIOR to the appointment. If you do not have the referral or authorization, you may need to reschedule your appointment or you will be responsible for the charges.

It is your responsibility to pay any deductible, co-insurance, or any other balance not paid by your insurance carrier.

Please remember your insurance policy is between you and your insurance company and not with the insurance company and your doctor.

The intention of this notice is to clarify our policies and procedures and to promote good communication between our patients and our office.

Please Check Box*
- I understand the billing procedures associated with this office and completely understand additional charges will be incurred if I fail to comply. I also, acknowledge that if I do not pay in full for services rendered, on the date of service, I herby assign all medical and/or surgical benefits to which I am entitled, including Medicare, Private Insurance and any other health plan to Tri-County Medical Clinic, P.C. A photocopy of this policy is to be considered as valid as the original. I further authorize Tri-County Medical Clinic, P.C. be allowed to release information regarding my treatment in order to receive payment.
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Office Billing Policy

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