Financial Policies
FINANCIAL POLICY
MELISSA SELKE, M.D., P.C.
Patient Name: _____________________________________
Date of Birth:_________________
BASIC POLICY: Payment for services is due in full at the time service is provided in our office.
FOR PATIENTS WITH INSURANCE: We bill most insurance carriers for you if proper paperwork is provided to us and, if required, you have us listed as the primary physician on your plan. We will also bill most secondary insurance companies for you. Co-payments and deductibles are due at the time of service. If an insurance carrier has not paid within 60 days of billing, professional fees are due and payable in full from you.
MEDICARE PATIENTS: We accept Medicare assignment. In addition, we will submit the paperwork to your secondary insurance carriers for your convenience.
NON-COVERED SERVICES: Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial. Physical exams, well-child visits, immunizations for foreign travel or prevention, IUD placement, and cosmetic skin surgery may be some of the non-covered services under your health insurance policy.
CO-PAYS: All co-payments are due at the time of service. If not paid within 5 business days from the date of service, a $10 surcharge may be added to your co-payment.
CREDIT CARD PAYMENTS: A $3 surcharge will be added to all payments made by credit card to partially offset the credit card fees our office must pay to the credit card agencies each time a credit card is used for payment.
COLLECTIONS: If an outstanding balance is not paid within 90 days of your first invoice, and a payment plan has not been documented, the balance will be turned over to a collection agency and any fees or surcharges imposed by the collection agency will be your responsibility, along with your full outstanding balance. The present collection agency fee is 35% of your outstanding balance.
BOUNCED CHECKS: A $30 fee will be added to your outstanding balance if your check bounces. If the check is redeposited and clears, the fee will be reduced to $20.
MISSED APPOINTMENTS: We require a minimum 24 hours notice for any cancellation of scheduled appointments. A fee of $25 will be charged if sufficient notice is not given or if you arrive more than 30 minutes late for your appointment and are unable to be seen by the doctor.
The patient is ultimately responsible for all professional fees.
I have read, understand, and agree to the above financial policy for payment of professional fees.
Signature: _________________________________________
Date:_____________________________________________
Relationship, if minor:_________________________________
__________________________________________________
ASSIGNMENT OF INSURANCE BENEFITS:
Patients with insurances please read and sign below:
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans, to Melissa Selke, M.D., P.C.. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand I am financially responsible for all charges whether or not paid by insurance, for all services rendered on my behalf or my dependents. I hereby authorize Melissa Selke, M.D., P.C. to release all information necessary to secure the payment.
Signature:_________________________________________
Date:_____________________________________________
Relationship, if minor:________________________________