FINANCIAL POLICY AGREEMENT

SOL MEDICAL GROUP

FINANCIAL POLICY AGREEMENT
I have read this financial policy and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. Thank you for choosing SOL Medical Group for your medical needs. We are committed to providing you with quality, and affordable health care. We ask all patients to review and sign this policy, asking questions, as necessary. A copy will be provided to each patient upon request. REGISTRATION: All patients must complete our patient information packet, which will be entered into our computer to maintain accurate information for proper billing. We must obtain a copy of your driver’s license or ID and a current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of the claim. PAYMENT TYPE: We accept cash, and debit/credit cards of $10.00 or more. INSURANCE: SOL Medical Group participates in most insurances’ plans. IF your insurance is not a plan we participate in, full payment is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit. PATIENT PAYMENT: ALL COPAYMENTS AND DEDUCTIBLES ARE TO BE PAID AT THE TIME OF SERVICE. This arrangement is part of your contract with your insurance company. Please let us know if you have any questions or concerns.
PATIENT
First Name
Last Name
WITNESS
First Name
Last Name

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Debit/Credit Card on File Policy

We have implemented a convenient payment policy using Credit Card on File. As you are aware, the
current state of healthcare in our market has resulted in significant changes in insurance policies, copays,
deductibles, and premiums. Unfortunately, a great deal of the financial burden now falls on the patient.
There are insurance plans that require deductibles and copayments in amounts unknown to you, or to us,
at the time of your visit. You will be asked for a debit/credit card at the time you check in to leave on file
in your patient chart. This information will be held securely. The amount that we will charge to the card
on file will be the financial responsibility that the insurance company requires you to pay.
Card on File:
What are the benefits for me? Patients who have a card on file will no longer have to worry about
statements and mailing in payments. You can also use it to pay for future visits without having to bring
your card. Having a card on file will make check in easier, faster, and more efficient for patients.
How does this work? During your visit, we will ask you to sign a “debit/credit card on file agreement”.
When our office receives remittance advice/information from your insurance company (typically 2-4
weeks), any remaining portion of charges will be charged to your card. We will notify you FOUR TOO
FIVE DAYS BEFORE the charge is due to take place, and you may call our office if this presents a
problem/hardship for you. A receipt can be either emailed, texted or picked up at your next visit. If the
payment is declined, we will request updates card information or us an alternative form of payment.
How can I assure my card information will remain safe? Under HIPPA, we are under strict state and
federal rules and guidelines to protect patient privacy and the card is considered protected health
information. We will store your information on a secure and encrypted sire, which will enable us to run
bank transactions through our company computer system.
I never had to do this at any other doctor’s office: This may be different from what you have been
used to, but it is becoming common practice in most health care facilities with the changes that have come
about in the insurance industry. Many practices now require a card on file, and payment at the time of
service. This policy is being instituted, to simplify and enhance your patient experience. This change will
lower the practice’s administrative expenses to allow us to focus more on providing the exceptional
patient care that you have becomes used to at SOL Medical Group. ** The Law may require confidential
epidemiological reporting. It is the intention to comply with applicable laws and regulations.