To avoid any misunderstandings and ensure timely payment for services, it is important that you understand your financial responsibilities with regard to your health care.  You are required to sign our Authorization and Consent to Treatment Form before receiving medical services. Your signatures will attest that you understand your financial responsibility regarding the necessity and appropriateness of the services provided.

PATIENT RESPONSIBILITY

It is the sole responsibility of the patient or their legal representative to pay all charges for services provided.

You are responsible for co-pays/ co-payment, coinsurance or deductible that may apply after verification of your insurance plan, and will be due at the time of service. All prior balances must be paid before visit begins. For each visit you must provide all current demographic information such as current address, insurance information, and telephone number.

You are responsible for understanding the limitations of your insurance policy.

MISSED/CANCELLED APPOINTMANTS. 

Please notify us at least 24 hours before your appointment to avoid charges. The charge for a missed appointment is $30.00. and $ 50.00 for a physical.  This fee cannot be billed to the insurance company and must be paid before scheduling your next appointment. 

CARD-ON-FILE PROCESS/ AUTHORIZATION FOR CREDIT CARD ON FILE

Well Timed Healthcare requires and securely keep a credit/debit/HSA card on file. The charges/balances for which you will be responsible if any, will be charged to the card on file for your convenience. A receipt of all transactions will be sent to your email that you provided. Please call our office if you have any question about your balance.  Parent or legal guardian are responsible for all charges that relates to the care of a minor. If you are uninsured and demonstrate financial need and complete the required paperwork by calling the office, financial assistance may be available.

PAYMENT PLANS
Payment plan may be available for large balances, your card on file will be billed at a mutually agreeable timeframe.

UNINSURED/NO INSURANCE
We accept Credit Cards, Debit cards, Master card, Visa, and others cards. DISCOUNTS MAYBE AVAILABLE IN SOME CASES.

 NON PARTICIPATING INSURANCES

If we do not participate with your insurance plan, it is your responsibility to pay in full at the time of your visit. Then you will receive an invoice to be submitted to your insurance carrier for reimbursement.

INSURANCE PLANS

When you have insurance benefits you have a contractual agreement between you and the insurance company, not with Well Timed Healthcare. It is your sole responsible to understand covered services that are covered under your policy at the time of service. Please contact your insurance carrier to verify your benefit and coverage. You are responsible for all uncovered services.

Claims are filed/sent to the insurance company are done as a courtesy to our patients. Your insurance will be verified at the time of your visit. Proof of identification must be provided for all visits. If your insurance has been changed it is your responsibility to provide the correct/updated insurance information to the office. All co-payment, coinsurance or deductible that may apply are due prior to start of service.

 OUTSTANDING BALANCES. 

You are the responsible party for all balances that the insurance company does not pay. You will receive an Explanation of Benefit (EOB) in the mail that will alert you of your balance. You may occur additional balances from other providers not limited to other diagnostic related providers, radiology, or laboratory. An email will be sent to you about your pending balance. These statement balances are can be obtained and paid for in the Patient Portal and is due within 10 business days. Payment Arrangement can be made by calling 301-401-7999 if arrangement have not been previously made. After 90 days of an outstanding balance your balance may be transferred to a collection agency for collections. The cost of collections will be an added to your balance.

NO SURPRISES ACT / GOOD FAITH ESTIMATE OF CHARGES

If you are not using insurance or if you have no insurance to pay for your care, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost Under the NO SURPRISES ACT. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-888-774-8428. On our website, WellTimedHealth.com, you may find this on the patient portal about our financial policy.

ASSURANCE OF PAYMENT

I agree that I am responsible for all uncovered/not covered charges by my insurance plan for services that are provided by my provider.   Thank you for choosing us as your healthcare provider!

By my signature on this form, I also agree to pay any requested fees as established by Well Timed HealthCare. By Signing Below, I Am Agreeing That I Have Read, Understood, and Agree to The Items Contained in this Financial Document On This Date.  Please enter your full legal name as your electronic signature. To be signed by the patient’s parent, or legal guardian if the patient is a minor or otherwise not competent

Name and Relationship of Person Signing, if not Patient:  ______________________________________________