Thank you for choosing CoreLife, Inc (“CLI”) as your healthcare provider. We realize that the
cost of healthcare is a concern for our patients and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our
relationship. The following is a statement of our Financial Policy, which you must read, agree to,
and sign prior to treatment. Carefully review the following information and please ask if you have
any questions about our fees, policies, or your responsibilities.
Provide Accurate Information: You have a responsibility to provide accurate and complete
information about your health history, mailing address, health insurance and other billing
information. If any information changes-name, address, phone, insurance coverage, etc.- you
must inform this practice immediately. Insurance denials or billing errors due to patient supplied
information will result in the immediate transfer of the account balance to the patient’s immediate
Know Your Insurance Coverage and Benefits: Your health insurance coverage is a contract
between you and your health insurance carrier. Patients are responsible for understanding
their health insurance coverage(s) and benefits. There may be limitations and exclusions to
coverage. You are responsible for any charges not covered by your plan.
Insurance Accounts: We ask that you present your insurance card at every visit. If you fail to
provide us with the correct insurance information at each visit a waiver must be signed and you
may be responsible for payment for all services provided.
Co-payments are due at the time of service, as it is a requirement placed on you by your
insurance carrier. Please help us by paying your co-payment at each visit.
We will file claims to the insurance companies we contract with, provided that you authorize
the “assignment of benefits” for payment directly to our practice. For plans that we participate
in, the practice will accept payment based on contractual agreements. You agree to pay any
portion of charges not covered by insurance.
For insurance plans we do not contract with, we will file claims as a courtesy, provided that
you authorize the “assignment of benefits” for payment directly to our practice. If your
insurance does not pay within 60 days, you will be responsible to pay the balance of unpaid
charges and follow-up with your insurance directly.
Self-pay Accounts: Self-pay accounts are patients without insurance coverage or who are
unable to provide us with valid insurance information. If a patient is able to provide valid
insurance information within 30 days of the original date of service a claim will be filed with the
insurance carrier. If the insurance carrier issues payment for services rendered the patient will be
issued a refund based upon the insurance payment. Self-pay patients are responsible for
paying 100% of charges at the time services are rendered.
Statements: A statement will be sent to you once a balance becomes patient responsibility and
will continue every 30 days thereafter. Unless you notify our office within 30 days of receiving
your statement that you dispute the validity of the balance or any portion thereof, we will assume
the balance is correct and valid.
Collection of Outstanding Balances: All outstanding balances shall be due within 14 days
unless prior monthly payment arrangements have been made in writing. Balances that remain
outstanding after 90 days or more may be referred to an outside collection agency/attorney and
may result in termination of medical care by CLI. If your account is referred to an outside
collection agency/attorney you may be responsible for paying any incurred collection
Types of Payments: Our practice accepts Debit, Visa, Mastercard, American Express, and
Discover. Cash, check or money orders are also acceptable methods of payment. If your check
is dishonored (returned for non-sufficient funds) you will be required to pay an additional fee of
Missed Appointments: It is important that you appear for all scheduled appointments. By way
of courtesy, we usually (but need not) call to confirm your appointment a day or two before the
scheduled visit. If speaking to you is not possible for any reason, we attempt to leave a
reminder message on an answering machine or voice mail. Your failure to appear for a
scheduled appointment or to cancel an appointment at least 12 hours prior to the visit will
result in a missed appointment fee of $35. This policy is aimed at minimizing waiting time and
ensuring availability of medical care for all of our patients. We recognize the fact that there may
be circumstances which may not permit you to give 24 hours prior notice but such occurrences
are exceptionally rare and shall be considered on a case by case basis.
Treatment of Minors: The parent(s) or legal guardian(s) is responsible for full payment and will
receive the billing statements. A signed release will be required to treat unaccompanied minors.
Miscellaneous Fees: Certain services (e.g. family conferences, completing forms, producing
narrative reports, personal letters, etc) may entail additional fees not covered by insurance.
Payment in full is expected at the time such services are rendered.
Regardless of any personal arrangements that a patient might have outside of our office, if you
are over 18 years of age and receiving treatment, you are ultimately responsible for payment of
service. Our office will not bill any other personal party.
By signing bellow, I fully understand and agree to the terms of the CoreLife Financial Policy.