Thank you for choosing us as your health care provider. We are committed to your treatment being successful.
It is the patient’s responsibility to provide current insurance information. We will obtain a copy of your insurance card at your initial visit. Please bring your insurance card every time you visit the office, as we may occasionally request a copy to update our records. If current insurance information is not on file at the time of service, the patient is responsible for paying all charges for the services.
Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your claims for you. However, we will not become involved in disputes between you and your insurance carrier. This includes, but is not limited to, disputes with your insurance company regarding deductibles, co-payments, non-covered charges, and “usual and customary” charges. We will supply, upon request, reasonably necessary information to support our charges. It is your responsibility to fully understand your plan and any health saving accounts you may have. You are ultimately responsible for the timely payment of our charges.
Co-pays, deductibles, and co-insurance
Our patients use a variety of insurance plans. A large number of these plans now have high deductibles. We query your insurance company to confirm eligibility, co-pays, and outstanding deductibles. If you have NOT met your deductible for the plan year, we will estimate your financial responsibility and ask you to pay the balance before you are seen by your provider. We require all patients to pay their estimated deductible, co-pay, co-insurance, and patient account balance before services are furnished in our office. We will bill you for any remaining balance after your insurance has processed our claim.
Method of payment
We accept cash, checks, Visa, or MasterCard. Subject to the previous paragraph, you may pay in person at our office, by mail, or with a credit card on our online patient portal. Any unpaid balance past 90 days will be automatically charged to the credit card on file (see Credit Card on File Policy). If the credit card is declined, you will be assessed a $30 late fee. The charge for a returned check is $30 plus any bank fees incurred. This will be applied to your account in addition to the insufficient funds amount. If any check of yours is returned, we may place you on a “Cash Only” basis. Absolutely no post-dated checks will be accepted.
Uninsured or non-covered insurance plans
If our clinic does not participate with your insurance policy or you have no insurance, payment for your office visit is due in full before you are seen by your provider. Payment for any additional services rendered during your office visit is due upon rendering of the services.
If your balance is more than you are able to pay, our billing office will consider accepting a reasonable payment plan for your account. It is your responsibility, however, to contact our billing office at 316-682-1803 to request a payment plan. Any request for a payment plan will be accepted or rejected in our sole discretion.
Past due balances are due before we will schedule a new appointment. We ask that full payment be made at the time of service unless prior arrangements have been made through the billing office. If your insurance company has not paid the balance in full, you will be notified through the explanation of benefits that you receive from your insurance company. Any account with a balance that is more than 120 days past due may be turned over to collection agency for further collections. Any account that is turned over to collections will be assessed a one-time late fee of 25% of the past due amount and will considered for dismissal from our practice.
The parent(s) or guardian(s) is responsible for full payment and will receive the billing statements. We may require a signed release to treat unaccompanied minors.
Medical record copies
Northwest Family Physicians, LLC, and Mercy Medical Center, PA, utilize a medical records copy service. Their fees are set by the Federal Government Omnibus Rule. We reserve the right to charge a reasonable fee for copying your medical records.
Health care services are provided by Clifton Family Medicine, LLC, without regard to race, color, national origin, sex, age, disability, gender identity/expression, religion, sexual orientation, and / or status as a protected veteran. The providers and staff of Clifton Family Medicine, LLC are dedicated to providing medical care in the highest quality to restore and maintain health and preserve life. The health, safety, and well-being or our patients is our foremost concern.
Credit card on file policy
We require a valid credit card, debit card, or HSA card be kept on file for all patients. The card information is stored electronically in an encrypted formed and cannot be viewed by our office staff. Your signature below authorizes us to charge your card with your consent or when your balance becomes 90 days past due.
By signing below, I acknowledge that I have or may in the future give Northwest Family Physicians, LLC, or Mercy Medical Center, PA, a credit card, debit card, or HSA card to be saved on my family’s account. I authorize Northwest Family Physicians, LLC, and Mercy Medical Center, PA, to charge my card with my consent or when my account balance becomes 90 days past due.