• Insurance: If your insurance carrier is accepted, it will be billed. If you are using out-of-network benefits with your insurance carrier or are self-pay, payment in full is required at the time of service, unless other arrangements have been made in advance. You are responsible for knowing your insurance benefits (e.g. eligibility, covered benefits, co-payments), contacting customer services at your plan for questions you may have regarding your coverage, and any charges not covered by your plan. If you use your health plan, you agree that medical and psychiatric information are released to your insurance carrier.

• Secondary insurance: We will not initiate billing to an insurance that is secondary. We only bill the primary insurance company. You are responsible for activating & billing any secondary insurance coverage.

• Proof of Insurance: You must complete and/or update our Patient Information Form. You must furnish valid and up-to-date proof of insurance coverage. If you provide false or expired insurance information, you will be responsible for the balance of the claim. Any changes in insurance coverage prior to time of service must be notified. Insurance denials for termination of coverage will be automatically billed to you.

• Co-payments and deductibles: All co-payments and unsatisfied deductibles must be paid at the time of service. By contractual law your insurance company requires us to charge for, and you to pay for, all required co-payments, coinsurances, deductible and non-covered services.

• Claim submission: We will submit your insurance claims and assist you in any way reasonable to help get your claim paid. It is your responsibility to comply in a timely manner if your insurance asks you for additional information. The balance of your claim is your responsibility to pay whether or not your insurance company has paid, and you agree to make arrangements for prompt payment of the bill.

• Referral: If your managed care plan requires approval or authorization for referrals, it is your responsibility to inform the office of this requirement prior to referral. We require 72 hours notice to facilitate a referral request and cannot issue retroactive referrals.

• Missed appointments and Late Cancellations: Broken appointments represent not only a cost to us, but also an inability to provide services to others who could have been seen in the time set aside for you. It is your responsibility to remember your appointment. We require at least one business day (24 hours) notice of appointment changes and cancellations. Failure to comply with this policy will result in a $300 cancellation fee for a new patient appointment and $150 fee for Follow-up appointments. Please note that these charges are not reimbursed by insurance health plans.

• Prescription refills: New prescriptions will not be issued without first seeing your physician. Prescriptions for acute care or chronic conditions are written with an appropriate number of refills to complete the course of treatment or to last until your next scheduled appointment. All prescription requests are taken only during regular office hours and filled within 48 hours.

• Prior authorizations: We will honor prior authorization requests from the patient, but the patient is responsible for contacting their insurance company to have them forward the prior authorization form to our office. A $25 fee may be assessed for time to complete the prior authorization form. Any request for a forced change in your medication by your insurance company will require an office visit. The patient will need to ask their insurance plan what “alternative medications” are covered and provide a list to their Physician.

• Services not covered by you insurance: It is your responsibility to determine what services are and are not covered by your health plan. If you become involved in any legal matter that requires Dr. Sevy to testify in court or to prepare reports for the attorney or the court, you will be charged $500 per hour for these special services.

• Letters / Form completion: At the discretion of the Physician, letters and forms requiring medical review and Physician signature are subject to a $25 fee.

• Requests for medical records: In accordance with HIPAA regulations, you will need to sign a HIPAA-compliant Release of Information (ROI) form. The administrative fee associated with retrieving and copying medical records is based on the number of pages requested and this fee cannot be billed to your health insurance carrier. If you request a copy of your records, you will be charged ₵75 per page.