New Patient Medical History (Page 4 of 10) in pdf

Financial Policy

Thank you for choosing Weill Cornell Physicians for your health-care needs.

The following is our payment policy which we require you to read and sign prior your visit(s).

Patients have many different types of insurance and payment options for services rendered. Also, not all physicians in the

practice accept the same type of insurance. To ensure that we have accurate information to process your claim, we will make a

copy of your medical insurance and/or Medicare card at the time of your appointment.

You are required to inform us immediately of any changes in demographic information or medical insurance information.

Patients without medical insurance are required to pay in full at time of service.

We understand that financial hardships may affect your ability to pay in full. We will always do everything we can to

work with you. Please ask to speak to our Site Manager to discuss a satisfactory arrangement.

Participating Plans

You must present your insurance card, and if applicable, your insurance referral form, at every visit. We will submit bills

directly to your insurance company for payment on your behalf. Patients without insurance cards or proper referrals will be

asked for full payment at time of service. All co-pays, deductibles and non-covered services will be collected at time of service.

Non-Participating Plans

If your provider does not participate in your insurance plan, you are responsible for payment of all charges at the time of

service. We can submit the claim directly to your carrier or a claim can be mailed to you.

Payment in full is due at the time of service for all non-medically necessary services and/or cosmetic services.

Usual and Customary Rates

Your insurance policy is a contract between you and your insurance company. Our practice is committed to providing the best

treatment for your patients and we charge what is usual and customary for our area. You are responsible for payment

regardless of any insurance company’s arbitrary determination of usual and customary rates.

Payment

For your convenience, the following payment methods are accepted:

Cash, personal check, Visa, MasterCard, American Express, Discover

I have read the policy, I understand and agree to it.

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New Patient Medical History Page 4