Office Policies:

Co-payment Policy:      

Co-pays are due at the time of service. Any copay that is not paid within two (2) weeks of an office visit may incur a $10.00 service charge. In compliance with current legislation, any care provided outside of standard well check up will need to be documented and billed separately and will involve a copay.

Self-Pay Accounts Policy:   

A minimum deposit of $80 or the actual charges, whichever are less, are due at the time of service. If you are unable to pay in full, a payment plan must be set up. Any payment plan established will require a signed agreement with an initial installment payment due upon signing. Any agreed upon future monthly installment(s) will be automatically deducted from the account/credit card provided to the Practice on the agreed upon date(s).

Financial Policy: 

In consideration for the services rendered to me, agreement to payment for all amounts for which the patient/patient’s guarantor is financially responsible, in accordance with the rates and terms of the Practice. To the extent permitted by law, where insurance or other third-party benefits are insufficient in paying for all the services rendered, that I will be responsible for the payment of any balances due as determined by the respective provider of services, including deductibles, co- payments, co-insurances or other fees required by my insurer, HMO or other benefit plan.

 I understand that if I have not provided the Practice with accurate and current information regarding my insurer at the time of service, HMO or other benefit plan/third party payor which provides me with health care coverage, I will be personally responsible for the cost of all care rendered by the Practice.

 I agree to personally guarantee, jointly and severally, prompt payment of all sums due. I agree to pay all bills when presented. Should my account become delinquent and past due more than ninety (90) days, I understand that I will be responsible for a service charge of $25.00. This charge will be added to my account and, additionally a $5.00 per month fee will incur thereafter until my account is current.

Returned Checks Policy:   

In the event a payment is returned by our financial institution due to insufficient funds, there will be a $35.00 service charge added to my account for all returned checks.

Late Cancellations (Less than 24-hour Notice) Policy:    

The Practice will keep count of any visits that are cancelled within 24-hours of the scheduled appointment time. If repeated cancellations occur, the Practice reserves the right to charge a fee of $25.00 per occurrence and that this will be added to my account accordingly.

No-Show (Missed Appointment) Policy:   

The Practice reserves the right will keep count of any visits that are missed or a result of a ”no-show” for a scheduled appointment. If repeated no-shows or missed appointments (two or more) occur, the Practice reserves the right to charge a fee of $50.00 per occurrence and that this will be added to my account accordingly. In the event repeat “no-shows” occur, the Practice reserves the right to discharge any patient due to a breakdown in the patient-provider relationship.

After-Hours Service Calls Policy:  

The Practice offers an after-hours phone service in the case of emergent medical needs. This means that a medical provider is available for urgent medical advice or concerns via telephonic communication. In the event a provider responds to a call and provides documented care, Hollen Family Medicine reserves the right to charge a fee of $35.00 per occurrence and this will be added to your account accordingly. Keep in mind that this type of service is not covered by insurance and is solely the responsibility of the patient or patient’s guarantor.