Thank you for choosing Revive Innovative Healthcare PLLC. We ask all our patients to read and agree to our Financial Policy. We are happy to answer any questions you may have before you sign the agreement. The purpose of the policy is to help insure that we can focus on your care and to be transparent concerning finances. Unfortunately, patients who refuse to sign this are not able to be seen and will be subject to our appointment cancellation policy and fee.
In order to streamline our billing and payment system, Revive Innovative Healthcare requires that ALL patients have a valid credit/debit card on file or leave a retainer. There are no exceptions to this rule. The credit/debit card will be swiped (or entered in via the online service) the day of service and kept on-file using the latest end-to-end encryption security software. Our office is “PCI-compliant”, which means that we place a high priority on the security of cardholder data.
We thank you for choosing Revive Family Medicine. We ask all our patients to read and agree to our Financial Policy. We are happy to answer any questions you may have before you sign this. Unfortunately, patients who refuse to sign this are not able to be seen.
We strive for transparency. Our fees are available online at RevieFamilyMedicine.com and available in the office for your review.
All fees are due at time of service unless it is part of a package and an agreed upon payment schedule is in place.
Insurance We are “out-of-network” and are not contracted with any insurance. We can provide, upon request, a “superbill” (an itemized list of services provided) along with a receipt for paid services. This document can be submitted to your insurance provider for possible reimbursement. The superbill can also be used for your HSA/FSA records. Revive Family Medicine (RFM) makes no guarantee concerning possible reimbursement for any good or service provided. You are advised to check with your insurance provider to see what, if any, out-of-network, Naturopathic services your plan covers.
Health Savings Accounts and Flexible Spending Accounts (HSA/FSA): Most of our services are eligible for HSA or FSA. Covered services may vary based on your plan. Again, plans may vary and we cannot guarantee which services are covered. It is your responsibility to insure a service is covered.
If you wish to submit your superbill to your insurance, and your plan requires a referral or preauthorization, you must have one on file at the time of your visit. This is YOURresponsibility, not Revive Family Medicine’s, although we are happy to assist you if we can.
Laboratory services (such as bloodwork, urine tests, etc.) and pathology: We offer discounted lab rates for both members and cash based patients when billed through our office. Any services billed to an outside laboratories or to your insurance is solely your responsibility. There is a flat $20 lab processing fee for lab billed to the laboratory or to your insurance provider or any other third party.
In order to streamline our billing and payment system, Revive Family Medicine requires that ALL patients have a valid credit card on file or pay in full for services rendered.
The credit card will be entered today and kept on-file using the latest end-to-end encryption security provided by Stripe. Our office is “PCI-compliant”, which means that we place a high priority on the security of cardholder data.
If the credit card we have on file for you changes, please notify us IMMEDIATELY, by calling us. It is not uncommon for people to change or cancel their credit cards for various reasons, including when a credit card expires. That is quite understandable. If we run your credit card and it is denied for any reason, we reserve the right to charge an additional $25 administrative fee if we are not able to run a new credit card within 7 days. This is similar to the $40 fee that we also charge for returned checks. We will contact you or leave you a phone message on the phone number you provided for us, asking you to give us a call with the new number right away. We will key-in the new credit card number into your account, and that will become your new card on file, subject to the same financial policy as the card you gave us in-person when you were in our office.
If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give RFM a new, valid credit card which I will allow them to key-in over the phone. Even though RFM is not swiping or entering this card in person, I agree that the new card will still be subject to the Financial policy listed herewith and may be used with the same authorization as the original card which I presented in person. In addition, I agree not to initiate or pursue a chargeback or payment reversal after RFM has charged my credit card for any of the above reasons.
Cancelation Policy: “no show”, or late cancelation fee If you do not show up for an appointment or you cancel less than one business days’ notice, it means that other patients who want to be seen as soon as possible, can’t. We do not double-book appointment slots, which means that time allotted to you goes unused and could have been given to someone else. Therefore, we reserve the right to charge for missed appointments $55 per visit per patient when not canceled more than one business day in advance. Calling our voicemail over the weekend when the office is closed and canceling your visit for the following Monday is considered less than one business day’s notice and subject to our cancellation policy.
Accounts which are past due beyond 60-days are subject to a 1% per month interest charge. In addition, accounts which are more than 90- days past due may be subject to an additional $25 processing fee, in addition to the interest charge, and may go to collections. If the account goes to collections, your national credit rating may be affected. Luckily it is extremely rare for an account to go to collections. We will make every effort to work with you to get your balance paid in full. Temporary financial set back can happen to anyone, and we are happy to privately and confidentially work out a payment plan with you that works for you and for us. Please feel free to discuss this with our billing manager. We don’t want finances to ever come in the way of you or your family members from getting the best medical care possible!
I understand that I am responsible for payment for all medical services provided to me by RFM. I authorize RFM to charge my card for any outstanding services. I understand that this form is valid until I cancel this authorization through written notice to Revive Family Medicine.
(We offer income based assistance. If you are in need of financial assistance, please call our office so we can discuss criteria with you).