JEFFREY B. BROWN, MD FINANCIAL POLICY
Thank you for choosing Jeffrey B. Brown, MD for your gynecological needs. The following is a statement of our Financial Policy. All patients must complete this form before seeing the Physician.
YOUR CO-PAY AND OTHER CHARGES THAT YOUR INSURANCE DOES NOT COVER ARE DUE AT TIME OF SERVICE
WE ACCEPT CASH, CHECK, CREDIT CARDS (MASTERCARD / VISA AND DEBIT CARDS)
Regarding Insurance
As a courtesy to our patients, Jeffrey B. Brown, MD will file claims to any insurance carrier with whom we are participating providers. If the insurance company has not processed and paid the claim within forty-five (45) days from the date of filing the claim, or has denied the claim, the payment of the account in full then becomes the responsibility of the guarantor or the person bringing the patient to our office for treatment. The Tenncare plans we accept are Bluecare, Tenncare Select, PHP and John Deere. Payment is due within thirty (30) days from the statement date, and interest will accrue at the rate of 1.5% per month. $15.00 late fee will be applied monthly to patient balances over 60 days old.
Assignment of Benefits
It is the member's responsibility to understand their benefits. Each policy is individual and you should contact your insurance to confirm coverage for specific procedures. After hours visits (visits other than Monday-Friday (8:30am - 5:00pm) may require an additional co-payment. It will be necessary to have on file an original signature of the policy holder authorizing the filing of insurance for you or your child(ren). I understand that the services provided to me by Jeffrey B. Brown, MD may incur a decrease in coverage or no coverage at all. Furthermore, I understand that if I have not secured appropriate authorizations compiled with the terms of my health benefit plan I may incur a decrease in coverage or no coverage at all. I agree to be financial responsibly for the services not 9 covered.
Patient Balances
If you are unable to make payment in full, depending upon the balance due, our billing department may offer a short-term payment plan. Please call our billing department during normal business hours at (865) 531-7959. The surgery deposit of $300.00 is to be paid before your procedure; if your insurance benefits states you have out-of-pocket expenses to meet.
Other information
There will be a $25 return check fee on all returned checks. Habitual missed appointments, noncompliance of care and/or accounts turned over to collections could result in dismissing you from our practice. Please help us serve you better by keeping your scheduled appointments. In the event that we make an exception and allow you to be seen without your copay, there will be a missed copay fee of $10 for each occurrence.
Collections
In the event the undersigned fails to pay the demand and the account is turned over to an attorney for collection, I hereby agree to pay all costs and expenses of collection, including, but not limited to, attorney fees up to 40% of the balance due.
Payment Policy
Payment is due prior to being seen for appointment.
You will be asked to pay your co-pay prior to being seen for appointment.
You will be. asked to pay $25.00 if you do not know
co-pay amount.
Insurance has deductible and/or coinsurance you will be asked to pay $25.00 prior to being seen.
If no insurance $100.00 is due up front before being seen for appointment and balance due at check out.
MISSED/FAILED APPOINTMENTS
We charge for missed or failed to keep appointments that do not give a 24 hour notice.
You will be sent a letter on the first missed appointment. A second failed appointment will result in you being charged $25.00 and the possibility of being dismissed from our practice. This charge is not billable to your insurance and you will be responsible for payment of this charge and it will need to be paid prior to be seen on your next appointment. Appointment times are scheduled for our patients to help with the flow and to be sure the physician has adequate time to spend with you the patient. Giving us a 24 hour notice allows us to better serve you as a patient and/or to allow someone to be seen in your spot.