Policies and Financials


Eastside Neurosurgery

Our Patient Financial and Medication Policy

 Thank you for choosing our practice! We are committed to the success of your medical treatment and care. All patients must complete our online registration and medical history questionnaire. You will receive login instructions to the patient web portal when your appointment is made. Please keep this information available as you may go back to view your office notes after your appointment. While you may seem overwhelmed with all the paper work it really is necessary to make our practice run smooth for you, our patient. We believe that a good relationship is based on understanding and open communications. For your convenience, we have answered a variety of commonly asked questions regarding our financial policy and our policy on medication refills. If further information is needed regarding these policies, please ask to speak to our Billing Specialist or the Practice Manager. Co-pay There are hundreds of insurance programs. Each is unique with its own set of policies, rules and types of coverage. It is important to remember that your medical insurance policy is a contract between you and the insurance company. Because insurance benefits and coverage plans are so diverse, we can make no guarantees with regard to what your insurance will or will not cover. You, the patient, are the one ultimately responsible for payment on your account. We do collect co-pays and balances at the time of your appointment. If you are unable to pay your co-pay at the time of your office visit, a $10 charge will be added to your account to help defray the costs involved in billing you. Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Due to new regulations and practices that are now in effect according to the Patient Protection and Affordable Care Act, it is our office policy that all patients read and sign a Financial Policy Statement. Under the Affordable Care Act, individuals who are receiving cost savings, are given a three-month grace period to pay insurance premiums before they can be cancelled with the following guidelines: During the first month, the issuer has to pay any claims. During the second and third months, the issuer can pend claims if premiums are not paid. At the end of the third month, claims will be paid as appropriate if the individual settles all outstanding premiums. If the individual does not settle all outstanding premium payments, claims would be denied and become the sole responsibility of the member. If your insurance premiums are not paid and/or your insurance is not active for any dates of service, you are completely financially responsible for any charges that will be incurred. This includes any office or surgery charges; therefore, you may be asked to provide us with proof of paid insurance premiums prior to services being rendered. As the insured individual it is your responsibility to know and understand your insurance policy and benefits. We will do all we can to try to keep informed of your policy as well. How May I Pay? We accept payment by cash, check, money order, Visa, MasterCard and Discover. For your convenience, our billing office is staffed Monday through Friday from 9:00am to 5:00pm. The phone number is (313) 343-7907 or (313) 343-8837. You are expected to make payment in full upon receipt of a billing showing your balance due. Other payment plans or options may be available, please contact our Billing Specialist for this information. When is My Account Delinquent? An account is considered past due 30 days following billing unless other arrangements have been made. Unpaid accounts beyond 120 days are considered delinquent and may be forwarded to a collection agency. Do I Need Referral? If you have an HMO plan, you will need a referral authorization from your primary care physician. It is your responsibility to obtain this referral authorization. If you arrive at your appointment and do not have the proper insurance referral your appointment will be rescheduled. If you were injured at work and have filed a claim with worker’s compensation, we do require written authorization from your work comp carrier in order for you to be seen. If it is disputed worker’s comp you will need to provide us with a letter of dispute from your carrier. If this is an auto related injury we will need the name of your auto insurance carrier along with the claim number, claims agent’s name and phone number and the date of the accident. What About Missed* Appointments? Office hours are by appointment only. We would appreciate your help and courtesy of a call if you are unable to keep an appointment. Please notify our office at least 24 hours prior to the appointment time. We reserve the right to charge you a missed* appointment fee of $50 and 2 non cancelled appointments are grounds for patient discharge. Our office does make appointment reminder calls prior to your appointment. Please be sure we have your current phone numbers on file to ensure that you receive your appointment reminder call and that your appointment is not missed. (*Missed appointment is the equivalent of not calling to cancel your appointment or just not showing up.) How Are My Medication Refills Handled? Our policy is for the patient to call our main number at (313) 343-7900 option #3 or you may call the confidential medication line directly at (313) 343-6343. Requests are usually handled within 48 business hours. Please be advised that your physician is in surgery 2-3 times a week so processing times may vary depending on the availability of your doctor, who, for your safety must review each request prior to refilling. Under no circumstance will medications be called in over the weekend. Please be sure to allow enough advance notice for medications to be called in so that you do not run out of medications or require a refill on the weekend. Films/CDs (MRI, X-Ray, CT-Scan, Angiogram) During your appointment, your doctor will review your radiology films, not just the report. This is the safest most accurate way for us to treat you, our patient. Therefore, it is required that you inform us where your tests were done prior to your appointment.  You will then be advised as to whether or not you will need to pick up your films and bring them to your appointment. Once your appointment is over, your films will be returned to you. Current Office Fees $50 – Missed appointment fee $30 – Medical records copy fee $15 – Form fee $10 – Administration fee added to co-pay if not paid at time of service $10 – Office note request fee   I have read, understand and agree to the above financial and medication policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductible are my responsibility. I hereby assign medical benefits due on my behalf to be paid directly to Eastside Neurosurgery, P.C. 1 hereby consent to the release of medical information necessary to process any insurance claims and to any other doctor for the continuation of my medical care. I understand that a photocopy of this release is as valid as the original.     Printed Name: _____________________________________________________   Signature: _________________________________________________________   Date: ____________________________________________________________


  Financial Policy – Click Here to Download / Print