North Texas Diabetes & Endocrinology P.A. 
				            	4101 Kirkpatrick Ln
				               Flower Mound, TX 75028
				        Ph: 214-513-2300 Fax: 214-513-2333

					FINANCIAL POLICY

Thank you for choosing us as your Endocrinologist. Please read our financial policy carefully and sign below.

Payment for services is due at time services are rendered. We accept cash, checks, debit cards, MasterCard and Visa.  Our office collects copays, unpaid deductibles, and coinsurance at the time of service. If you are unable to pay the full copay, you will be asked to reschedule your appointment.  Returned checks will be subject to a $30 charge.

              Please remember that our relationship is with you, not with your insurance company. 
               Your insurance policy is a contract between you and your insurance company. 

If you have insurance, we ask that you provide us with the information at the time of the visit.  As a courtesy, we will file your claim to your insurance and Medicare if we are in-network. 
Please inform the receptionist if you have any changes in your insurance or have received a new insurance card. 
Please provide us with details of both primary and secondary insurance. If you fail to provide us with the correct information at the time of service or at the latest within 30 days of service, we will not file a claim to your insurance and you will be billed the full fees. 

Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. You will receive a bill for any services not covered by your insurance company. After your claim is processed, you may still have a remaining deductible. You will be billed for the amount that your insurance company assigns towards your deductible.

Your insurance company may require additional information to process your claim. Your insurance company will request this information in writing. Our billing department will also notify you that your insurance is requesting more information. It is very important that you provide your insurance company with the information necessary to process your claims. You are allowed 10 days to get this information to your insurance company. If you fail to do this, the balance will become your responsibility and you will receive a statement from us for payment in full. 

We ask that you pay all bills due within 30 days of receipt of your statement. If we do not receive full payment for any outstanding bills in a timely manner, your account may be forwarded to a collection agency. 

It is required that self pay patients with no insurance pay the full amount due at the time of service. If you are unable to pay the full amount at the time of service, we will ask you to reschedule your appointment.                                                                       

				     REFERRALS

If your insurance company requires a referral from your primary care physician, it is your responsibility to get us this referral. Our office does not give appointments if we do not have the referral in our office at the time of scheduling. If you do not obtain a referral and one is needed, or if your referral has expired at the time of visit, you will be considered a self pay patient and will be responsible for the entire bill. Please remember it is the patient’s responsibility to have their PCP’s office renew referrals that are expired. Failure to do so may result in non-payment by your insurance company and you will be responsible for all outstanding charges. 

BROKEN APPOINTMENT POLICY

Our office requires 24 hours (1 business day) notice for all appointment cancellations and reschedules. There is a $25 fine for all broken appointments. All same day cancellations are considered broken (missed) appointments. Messages left on voice mail after office hours for cancellations of next business day appointments are also considered missed appointments. Any patient who has missed a total of 3 appointments may not be given any future appointments.

I ______________________________________do hereby affirm that I have read and understand the above policies.                     (Please print name)

Patient Signature ______________________________________      Date___________________________________
											Rev.3/07