COLLECTION FEES
You understand that in the event your account is placed in a collection status, any fees incurred as a result of this will be added to your outstanding balance. This includes late fees, collection agency fees, court costs, interest and fines. Also understand that these fees will be your responsibility to pay in full.

PAYMENT
Is due at the time of service. We accept VISA, Mastercard, Discover, cash and checks as payment. This includes your deductible, copay and coinsurance. If you do not have insurance, payment in full is expected on the date of service. 

SELF PAY PATIENTS
A prompt pay discount is applied to all payments received at the time of service. Charges for supplies, tests, immunizations, or medications are never discounted.

FORM FEES
There will be a $6.50 charge for all records copied for you.

RELEASE OF INFORMATION
You hereby authorize and direct Babson & Associates Primary Care P.C. to release to governmental agencies, insurance carriers, or other who are financially liable for such professional medical care, all information needed to substantiate claim and payment. 

ASSIGNMENT OF INSURANCE BENEFITS
You authorize Babson & Associates Primary Care P.C. to use and disclose any and all medical information to any facility, insurance company or entity pursuant to the coordination of care. You assign all insurance payments to Babson & Associates Primary Care P.C. 

DIVORCED PARENTS OF PATIENTS
the custodial parent who signs their minor child into our practice on the date of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment or communication. We will communicate about treatment and payment with the parent who signs in that day. Parents are responsible between themselves to communicate with each other about the treatment and payment issues. 

CANCELLATION OR MISSED APPOINTMENTS
If you do not cancel your appointment within 24 hours there will be a charge of $25.00 added to your account that you are responsible for, it will not be billed to your insurance. Fees may be higher for missed appointments for cash pay programs.

INSURANCE
As a COURTESY to our patients we bill all insurance. We are participating with a large number of insurance plans but it is up to you to check your benefits and ensure we are in network with your insurer. As insurance plans can vary greatly, there are some things that your insurance may deem non-covered. If your insurance determines a service to be non-covered, you will be responsible for the charges. Payment is due upon receipt of your statement. You, the patient, are responsible for providing proof of insurance and photo ID at the time of service.

Babson & Associates Primary Care offer special cash pay programs that are separate from the general family practice clinic. These programs are Medication-assisted treatment program (Suboxone); Immigration physicals for US Citizenship and travel vaccines.

RESPONSIBILITY FOR PAYMENT
You understand that you, personally, are financially responsible for charges not covered by the assignment of insurance benefits. 

PRIVACY PRACTICES
You have the right to review the Notice of Privacy Practices prior to signing the consent and a written copy is available upon request.

FINANCIAL POLICY

Babson & Associates Primary Care, P.C.

ACCOUNTING PRINCIPLES
Payments are applied to the oldest dates of service first when received from the patient. Insurance payments are posted to the corresponding date of service.

You may revoke your consent in writing at any time.

 Babson & Associates Primary Care P.C. reserves the right to revise its Notice of Privacy Practices at any time. Please contact our office for the most current Notice.

RETURNED CHECKS
Will be assessed a minimum of $30.00 service charge. All bad checks are subject to collections and any incurred fees from the collection agency.