Patient Financial Policy Form

Please click here to download the form: Patient forms_financial office policy

Here is a copy of the form:

Financial/Office Policies

Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment and care.

For your convenience, we have answered a variety of commonly asked financial and office policy questions below. If you need further information about any of these policies, please contact our billing service. Here is the name and contact information of our billing manager:


Phone Number: (908) 654-1200

How May I Pay?

We accept payment by cash, check, VISA and Mastercard.

What Is My Financial Responsibility for Services?

You will be financially responsible for all copays and/or deductibles at the time of service, depending on the type of insurance plan you have. If you do not have insurance, payment in full is due at the time of service unless prior payment arrangements have been discussed with our billing service.

What if my insurance doesn’t pay?

It is your responsibility to know what is covered and what is not covered by your insurance plan. If your insurance chooses not to pay Prescott Cardiology for whatever reason or they choose to delay payment, YOU will be responsible for payment. If payment is not received from your insurance company within 60 days you will become responsible for the outstanding balance.

What if my account becomes delinquent?

Patients will be sent a monthly statement detailing any amount owed to The Heart Specialists Group, LLC. Please make sure that our front office staff has your current mailing address. If our billing service receives no payment or response from you for the 30 days after the statement is mailed, we will assume that you do not intend to pay for the services or to set up payment arrangements.

Delinquent accounts will be sent to our collection agency for recovery. If your account is sent to our collection agency, you will be responsible for all fees incurred from the collection agency.

What if I write a check that is returned to your office unpaid?

Our returned check fee is $30.00. If more than one returned check is received on your account, we will require that future payments be made by cash, cashier’s check or credit card. If you do not bring in payment for the check and returned check fee, the check will be filed with the District Attorney’s office for collection. All fees incurred in the filing will be your responsibility as well.

What if I need a form completed by the office or physician?

There is a charge of $25.00 for every form that needs to be completed. We require 7 to 10 business days to complete any form. Due to the high number of patients in Prescott Cardiology, as well as the dozens of forms we receive weekly to be completed, chart notes to be read/reviewed/and commented on, letters to be authored and typed, and so on, the amount of time the physicians have to actually see patients is reduced. Therefore, this charge has become necessary and we will be unable to

waive that charge.

What if I need a copy of my medical records?

We require a signed medical records release before processing any records requests. You may receive a free copy of your medical records at any time. Please be aware that it may take up to fifteen (15) days to complete your request.

What happens if I am late to my appointment or I fail to show up?

We recognize that patients may need to cancel or change an appointment but request that they provide at least 24 hours notice so we may offer their appointed time to another patient.

If you arrive over 15 minutes late to your appointment you may be asked to reschedule as this delay affects not only the physician, but other patients that are scheduled after you.

For office visits, there will be a $25.00 charge for NO SHOW patients or patients who cancel their appointment less than 24 hours in advance, as these appointment times could have been given to patients in need.

For ultrasound appointments, there will be a $50.00 charge for NO SHOW patients or patients who cancel their appointment less than 24 hours in advance.

For our nuclear medicine department, there will be a $ 145.00 charge for NO SHOW patients or patients who cancel their appointments less than 24 hours in advance.

If neglecting to show up to your appointments begins to be a pattern, the physician may discharge you from the practice.

What if I need a prescription refilled?

If you are calling for a prescription refill you MUST contact your pharmacy unless the prescription is one which by law must be picked up from our office. Only prescription refill requests from a pharmacy will be honored.

Even if you are out of approved refills, please call your pharmacy and ask to have the medication you need refilled. The pharmacy will then fax us a request for your refill, which the physician can sign and fax back. This greatly reduces the time it may take for you to get your prescription if this process is followed.

You must allow up to 48 business hours for all refill requests to be processed.

What if My Child Needs to See the Physician?

A parent or legal guardian must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment of the account, according to the policy outlined on the previous pages.

Please remember that when you receive our statements you have already received quality care from our physicians and your insurance has been filed by us. We would then ask that you pay promptly upon receiving your statement.

Please feel free to contact our billing service if you have any questions regarding your statement or insurance. We are happy to answer your questions or to provide additional information.

I have read, understand, and agree to the above Financial Policy, No-Show Policy, and Prescription Refills Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.

I authorize my insurance benefits be paid directly to The Heart Specialists Group, LLC .

I authorize The Heart Specialists Group, LLC to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.


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