Auria Medical Clinics Policies,
1-Financial policy
Effective 1/8/2025
We ask that all our patients read, understand, and accept our Policies, as described below, if they agree. By completing, signing, and submitting this document, I consent to have read, understood, and agreed to the following policies. I had the opportunity to attend the practice to ask any questions, if necessary, for clarification of the following policies. I can download a copy of these policies online and keep then in my records.
1-Financial Policy
Initials: It remains my responsibility to verify that Auria Medical Clinics, LLC, the practice, is in my insurance network; if I fail to verify that, then it is my responsibility to pay all the applicable charges upon request.
Initials: I consent that I am responsible for all charges assigned to me by my insurance, to include, but not limited to, yearly deductibles, co-insurances, co-pays, non-plan coverages, and all charges/treatments not covered by my insurance.
Initials: The amount collected today is an estimate only. This is based on initial available insurance information and does not reflect the final balance. After your insurance processes the claim, you may be billed for any remaining balance. If the final insurance payment results in overpayment, you will be issued a refund. The credit amount may be applied to your future visits.
Initials: Please note that deductibles are determined by your insurance and not by us. Deductibles are collected in full at the time of your visit. Typically, deductibles for consultations are separate from deductibles for procedures.
Initials: Deductibles if NOT met:
New patients are charged $250, and follow-up visits are charged $180.00.
All procedure fees are due in Full at the time of the visit.
Initials: You will be charged $50 for any bounced back checks or credit card transactions in addition to the
owed principal.
Initials: If I fail to cancel my appointment 48 hours in advance, I will be charged $50 no-show fee.
Initials: Administrative fees:
I agree to pay the following administrative fees if applicable:
- Prior authorization that takes less than 60 minutes: $30.00
- Prior authorization and appeals that take more than 30 minutes and consume the physician's time: $100.00
- Requesting an electronic copy of your chart mailed to you or any other third party upon written request: $25.00
- Requesting a paper copy of your chart mailed to you or any other third party upon written request: $25.00 Base fee plus $0.99 for pages 1-20, $0.83 for pages 20-100, and $0.66 for pages 100+
- Requesting a notary public to mail any legal affidavit to your lawyer, which involves our physician's time out: $300.00, plus mailing fee.
Initials: Medicare beneficiaries are responsible for paying an annual deductible and, if applicable, 20% or more coinsurance.
Initials: If we do not have a contract with your insurance carrier, we cannot accept an assignment for reimbursement by your carrier. Therefore, charges are due and payable by you at the time of service. You receive a receipt to submit to your insurance as you will.
Initials: If the patient has a Guardian or chaperone, that person or entity is financially responsible for our charges.
Billing and Collection Policy:
Initials: I understand that:
The practice uses Healow Statement services. Within 7 days of receiving your insurance reimbursement, if there is any balance, you will receive a payable statement through your phone messenger, voice message, and email with links to pay.
If you fail to make the first request within 7 days, you will receive a printed statement in the mail every 2 weeks for 2 payments. There are links to pay the balance. If you fail to pay again, then the balance will be forwarded to a collection agency.
In addition to paying the balance to the collection agency, you will be charged 25% of the collected balance.
