Self – Pay Financial Requirements

Self-pay patients are required to pre-pay a down payment for the following amounts at check in:

• New Patient-Consult = $200.00
• Follow up - Established = $100.00
• Procedures Any Type = $700.00

(The price above is NOT the total cost for your visit or procedure - it is only the required down payment)

Resources for Financial Assistance

For all patients who need assistance in getting help for their medical bills the following resources are available for everyone who qualifies:

1. Monthly payment plans can be set up through our billing office by calling your financial counselor at 239-275-8882
   • Patient Last Names A-D x246
   • Patient Last Names E-K x242
   • Patient Last Names L-Q x275
   • Patient Last Names R-Z x273
2. Apply for Care Credit online at www.carecredit.com, call 1-800-677-0718 Care Credit gives you Special Financing, Low Monthly payment options, No up-front costs or pre-payment penalties
3. Apply for Medicaid online at www.myflorida.com/accessflorida, call 1-800-226-6735 or in person at any of the many locations.
4. The office of Vocational Rehabilitation, call 239-278-7150 to apply over the phone Monday – Friday 8am-5pm. This is a federal program for patients who have no insurance but a currently employed.
5. For Veterans without insurance, call Veterans Administration at 1-888-820-0230
6. For patients diagnosed with HIV, contact the McGregor Clinic (Ryan White Foundation) at 239-334-9555
7. For indigent patients, contact United Way Foundation at 239-433-3900
8. For patients with pre-existing conditions, you may apply online for the PCIP plan (Pre-existing Condition Insurance Plan) at www.pciplan.com or call 800-220-7898 for additional information.

Our Practice Financial Policy

The following sets forth the general financial policy of Gastroenterology Associates of S.W. Florida, P.A. Please review this information and sign where indicated.

The patient is responsible to provide the office staff of Gastroenterology Associates of S.W. Florida, P.A. with current, accurate billing / insurance information at the time of check in and to notify Gastroenterology Associates of S.W. Florida, P.A. of any changes in this information. Any patient with insurance coverage that is a Medicare replacement plan and have a secondary insurance plan; such as Medicaid, need to be aware that the secondary insurance will not pay for any portion of the bill and the patient will be responsible to pay for any remaining balances after the Medicare replacement plan pays.

The specialist co-pay (which can be different than my Primary Care co-pay) is to be paid prior to services being rendered. I understand that this is a contractual agreement that I have with my health plan and that Gastroenterology Associates of S.W. Florida, P.A. also has a contractual agreement with my health plan to collect co-pays at the time of service, and they are required to report to the carrier any enrollees failing to pay the co-pay.

There is a $15 Statement Fee that will be charged to my account if I do not pay my co-payment on the day of the visit.

There will be an insufficient funds fee of $25 charged to my account if an insufficient funds check is given for payment. I further understand that to rectify my account, I will be required to pay with cash, a money order, cashier’s check, or credit card.

There is a $20 fee to complete disability paperwork associated with my care that will have to be paid prior to the forms completion. I further understand that if additional disability forms (such as FMLA) are required then and additional $20 fee is required and will have to be paid prior to the forms completion.

There is a $75 fee if I do not give two business days advance notice when cancelling or rescheduling for any radiology or endoscopy procedures.

Medical records request are handle by a third party company “Health Port”. There is a standard fee of $1 per page, plus shipping and handling fees. A properly signed medical records release will be required in order to get the copy of your medical records. If you have any questions about your request call Health Port at 1-800-367-1500.

I understand that Gastroenterology Associates of S.W. Florida, P.A. will verify my insurance eligibility, deductible amounts, and coinsurance amounts prior to any elective procedures that I may have. I further understand that it is the policy to collect the deductible and/or coinsurance prior to scheduling my elective procedure. I further understand that the FEE I AM QUOTED IS AN ESTIMATE based on the anticipated procedure to be performed and the current information provided to Gastroenterology Associates of S.W. Florida, P.A. by my insurance carrier.

I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/deductible amounts) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with three (3) statements for any balance due after insurance payment. I further understand that if I have not made payment after the third “Final Notice” statement being mailed that my account will be sent to an outside collection agency. I also understand that I will be responsible for any collection, interest or attorney’s fee’s associated with the collection efforts.

I understand that the staff of Gastroenterology Associates of S.W. Florida, P.A. may contact me at any phone number that is provided to discuss financial responsibility, unless I submit a written request to restrict certain phone numbers where I can be contacted.

I understand that Gastroenterology Associates of S.W. Florida, P.A. will obtain the necessary authorizations prior to rendering treatment. I further understand that prior authorization is not guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier.

My signature below confirms that I have read and understand these financial policies and my financial obligation as pertains to the providers of Gastroenterology Associates of S.W. Florida, P.A.