Office Financial Policy

We are dedicated to providing the best possible care for you and want you to completely understand our financial policies.

Insurance Billing

As a courtesy, we will bill your primary insurance company for medical services rendered. Your insurance policy is a contract between you and your insurance company. If problems arise regarding coverage issues, we will work with you to help resolved them. However, you are ultimately responsible for understanding what is covered under your policy and for payment of medical services rendered by this office.

If you have medical coverage with two different insurance policies, including one provided by your employer, California law requires that you seek primary coverage under the insurance policy provided by your employer. This office only provides courtesy billing of your primary medical insurance company. We do not provide the service of billing secondary medical insurance policies.

Co-Payments and Deductibles

A co-payment is required for each office visit, as determined by your medical insurance policy. Payment is due at the time of service. We accept payment in the form of cash, VISA, MasterCard or DISCOVER. If you are entitled to reimbursement for such co-payments under a secondary insurance policy, it is your responsibility to process and collect this yourself. If we determine that you have not met your annual deductible at the time of your service, we may require a $50 payment. This will be applied towards the balance of your account.

Non-Covered Services

It is ultimately your responsibility to understand your policy. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Not all procedures are covered. Our office will try to establish if such services are payable within your plan.

Payment at time of service is required for the following:
Non-covered charges may include but are not limited to:

  • Immigration Physicals and accompanying paperwork
  • Lack of Medical Coverage
  • Cosmetic procedures

Miscellaneous Charges

The California Health and Safety Code, and California Business and Profession Code, state that Medical Offices may assess reasonable charges:

$25 – $100
(depends on research time)
Medical Records search and/or Copy
$50 Attending Physician Statements
$25 and up Paperwork/forms
(items such as DMV, school, sports etc)
$190 I-693 form
We reserve the right to charge a $50 fee for canceled or missed appointments Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. For cancellations, 24 hours’ notice prior to the appointment is requested.

I have read and understand Dr. Washington MD, Practice Financial Policies and I agree to be bound by its terms.
I understand and agree that such terms may be amended by the practice from time to time.

___________________________________ Signature of Patient (or responsible party if under 18 years of age)

________________ Date

______________________________________________________Please print patient name
rev 04/2014