Glendale Area Medical Association, Inc.

 

P.O. Box 375

850 Main Street

Coalport, PA 16627

(814) 672-5141

 

FINANCIAL POLICY

        We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time.  Your clear understanding of our Financial Policy is important to our professional relationship.  Please ask if you have any questions about our fees, financial policy, or your responsibility. 

-All patients must present insurance cards for each visit and complete our Patient Information Form before seeing their provider.  This information must be true and correct.  Your misrepresentation of this information will lead to dismissal as our patient.

-Full payment for self-pay and non-participating insurance is due at the time of service.

-We accept cash, checks and Visa/MasterCard.

Regarding Insurance

        If you have insurance with the following plans, we will bill on your behalf.  However, you are responsible at the time of service for your co-pay.  We participate with the following:

       

        If you have insurance with a carrier not listed above, we will provide you with a HCFA 1500 (standard insurance invoice) within one week of service for you to send to your insurance company.  We will no longer bill for secondary coverage and other nonparticipating insurance.

 

        Insurance is a contract between you and your insurance company.  We are NOT a party to this contract in most cases.  (We will inform you if we are a party to your insurance contract, and will handle your claims according to our agreement with the insurance company, if one exists.)  We file insurance claims as required by our agreements with the above listed carriers.  We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, usual & customary charges, etc., other than to supply you with factual information as necessary.  You are responsible for the timely payment of your account.

 

 

Sliding Fee Program

       

        As a grant recipient of the Public Health Service, we offer a discount on provider services.  This discount is in accordance with 42 CFR Part 51. C 303, and is based on the "Annual Revision of Poverty Income Guidelines."  To be eligible for this program, patients must complete eligibility for and receive pre-authorization.  You must also present proof of income.  To stay in accordance with federal standards, complete payment must be made the day of service to receive the reduced amount.  Eligibility will be reviewed as determined by the front office.

 

Patient Responsibilities

 

        All Patients must have current insurance information with them for each visit.  Co-payments will be required prior to your office visit.  Our office may refuse to see you without these.

 

Worker's Compensation

 

        Patients requiring treatment for work related injuries must have employer occupational injury reports.  The front office must be notified during each visit that the visit is for compensation.  Should you not have a occupational injury report, the office will require you to have your employer contact us within 24 hours.

 

Thank you for understanding our Financial Policy.  Please let us know if you have any questions or concerns.

 

Responsible party Signature ____________________________ Date____________

 

This policy will be in effect as long as you remain our active patient.

 

 

 

 

 

 

 

 

Home - Office Hours - Services - Scheduling - Fees - Providers - Staff  - GAMA board  -  Policies - Outreach - Scenes - History - Acronyms - Directions - Contact Us