Thank you for choosing Dr. Loop as your healthcare provider. He is committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.
Fees
Our fees are determined by the complexity of each case and different services used.
Regarding insurance
We will verify coverage prior to treatment and we will file all claims as a courtesy to you. If for any reason we are not able to verify coverage prior to your treatment, you will be charged for the treatment until verification is obtained. We cannot bill your insurance unless you bring us all necessary insurance information. We are not a party to that contract. You are assigning to this office the benefits to which you are eligible to receive for care rendered in this office.
Additionally, you authorize the release of any information to any insurance company, adjuster or attorney that will assist in the payment of a claim. We request a credit card on file if the insurance company should not pay claims or any balances owed should there be any difference in the amount owed.
Usual and Customary Rates (UCR)
Our practice is committed to providing the best treatment possible for our patients. We charge what is usual and customary for our area. Please be aware that some and at times perhaps all of the services may be non-covered services and not considered reasonable and necessary by medical insurance. All payments are due at the time of service.
Cancellation and Refund Policy
Doctor Loop understands that Change is a constant in all our lives and that unanticipated events can and will occur. However, in order to best serve all patients, and to honor each other’s important time schedules, the following policies are effective immediately once an appointment is scheduled. Mutual respect and courtesy for one another’s time and presence is very much appreciated and honored.
24-Hour Notice for Cancellations
If a patient needs to cancel or reschedule for any reason, at least 24 hours’ notice is required. This allows the opportunity for another patient to schedule an appointment. If 24 hours’ notice is not provided than full payment is required. If the practitioner needs to cancel the appointment for any given reason, they will make all efforts to do so with at least 24 hours advance notice.
No-shows
Patients who either forget or consciously choose to forgo their appointment for whatever reason will be considered a “no-show.” No-show appointments are non-refundable.
Late Arrivals
If a patient arrives late, the session may be shortened in order to accommodate following appointments. Depending upon how late the patient arrives, the practitioner will determine if enough time remains to start a treatment. Regardless of length of treatment given, the patient is responsible for a “full” session.
Refunds
All purchases are non-refundable. If you have made a purchase in error, prompt communication with Dr. Loop is appreciated.
Thank you for making the commitment to your health and wellness and I look forward to assisting you with my full heart.
Billing Options
There are two billing options available for you. Please select the one you prefer us to use for your visits. If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.
Option 1 - Private Pay – the discounted cash rate is only applied to the published rate if you pay at the time of service
Option 2 - Insurance (Medical or Auto Insurance)
You will be asked to sign "Authorization To Bill Insurance"
I understand that I must pay all co-payments and/or co-insurances not covered by my insurance company at the time of check in for today’s visit, and every visit hereafter. Dr. Loop will submit my claim for me to my insurance company. Although Dr. Loop verifies my insurance; I understand that this verification is not a guarantee of payment. I understand that any and all charges incurred at this office including co-payment, co- insurance, percentage due and/or deductibles or any other fees or services not covered by my insurance company are my responsibility. I understand that if these patient portions due are not paid at the time of service I will be subject to a $10.00 billing fee per month – no exceptions until the outstanding amounts are paid. I further understand that any unpaid balance over 90 days, can and will be sent to collections for recovery unless prior arrangements have been made.
I authorize my insurance benefits to be paid directly to Dr. Loop. I also authorize the provider to release any information and medical records required by my insurance company. I understand that I may revoke this consent by written request, at any time. No other records shall be released without my signed consent.
