Things to bring with you to each visit:
1) Current insurance card(s)
2) Photo identification
3) Your preferred method of payment for any cost shares due at the time of service
Insurance Companies: Participation and Billing
1) While Brevard Physician Associates, PLLC participates with most third-party insurance plans available in our area, it is your responsibility to verify that your BPA physician is currently participating with your plan and that you have obtained all necessary referrals PRIOR to your scheduled appointment. Failure to do so may result in your responsibility for any incurred charges.
2) We will ask you to provide your insurance card(s) at every visit. This is to ensure that the information we have on file is correct, and that your plan is current.
3) The Practice will submit claims to your primary and secondary insurance companies whether we participate or not, as a courtesy to you.
4) Except where your plan provides for automatic payment of benefits to the provider of services, by signing this form you authorize payment of benefits, otherwise payable to you, for services rendered by Brevard Physician Associates, PLLC. You agree that you are ultimately responsible to the provider for charges not covered by your benefit plan. By signing this form you authorize the release of any medical information required by my insurance carrier(s) to allow payment of medical benefits either to yourself or to the party who accepts assignment. A copy of this authorization may be used in lieu of the original.
5) Due to the wide range of insurance plans, we are unable to quote specific plan benefits. Please make sure you completely understand your individual insurance plan by contacting your insurance company directly to discuss your plan’s benefits.
Time of Service Payments
1) Co-payments, deductibles, and coinsurance are part of the contractual agreement between you and your insurance company. We may collect your co-payment in full at the time of service or bill at a later date. If your plan also has a Deductible and/or coinsurance that has not been met; we may collect a deposit of $100.00 (since we can only estimate the future amount due) at the time of service.
2) Patients without medical insurance coverage (self-pay patients) are responsible for all charges that result from professional or medical services provided by our physicians. We will charge you during the visit when you receive our services, unless we approve other payment arrangements.
1) The practice reserves the right to consider delinquent patient accounts that have not been paid for over 90 days. We reserve the right to submit such accounts for external collection efforts in accordance with state and federal regulations.
2) Should your account become delinquent, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.
Cancellation Policy and consent for text/electronic appointment reminders
1) Should you need to cancel your office visit appointment, you will be subject to a $50.00 charge unless you cancel with 24 hours business day advanced notice.
2) By signing this form you agree to receive text message, phone call and/or email reminders from Brevard Physician Associates, PLLC, as a courtesy to facilitate my scheduling needs and help avoid incurring in cancellation fees. You also agree that you are financially responsible for any charges incurred for missed appointments in which you did not give the required advanced notice.
Release of Information, patient rights and notice of privacy practices
1) The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information (PHI) is protected and is only to be used or shared in the minimum necessary fashion. Healthcare providers are to obtain their patient’s consent for use and disclosure of personal information to be able to carry out treatment, charge payment, or perform other health care operations. By signing this consent, you understand that your physician may need to provide necessary medical information to other physicians, pharmacies, hospitals, insurances companies, laboratories, and billing agencies. Refusing to consent to the use or disclose of your PHI prohibits the doctor from billing their services; scheduling your care at a hospital; or calling in a prescription to a pharmacy; or any other coordiantion of care needed. Under this law we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent to this document at some future time you may request to refuse all or part of your PHI. You may not revoke any actions that have already been taken which relied on this signed consent.
2) If you have any objection to this form, please ask to speak with our Office Manager.
3) By signing this form you consent for the practice to use and disclose Protected Health Information as required and/or permitted by law. You also acknowledge that you have been provided with these policies ahead of your appointment.