Billing and

Financial Policy

To Our Patients:
Thank you for selecting our office for your medical care. In order to prevent any misunderstanding concerning the responsibility for payment for medical or surgical services provided to our patients, the following is supplied:

1. The patient or the guarantor is responsible for payment for services provided by Digestive Health Specialists of the Southeast at the time of service unless prior arrangements have been made. The only exception is if Digestive Health Specialists of the Southeast has contracted with your HMO/PPO insurance plan to accept the insurance payment as payment in full after all deductibles have been met and all co-pays have been paid.
2. We will file a claim to your insurance company for each visit. If requested, we will furnish you with a copy of your bill for each visit, which contains all the information necessary for you to bill any personal reimbursement policies that you may have.
3. Charges for initial, return office visits, and any procedures performed will vary depending on the nature of your visit. Additional tests or procedures, such as a laboratory, radiology, or other diagnostic tests will be billed separately by those providers.

Insurance Procedures

Digestive Health Specialists participates with most area health insurance networks and will gladly file your medical claim for you. For information regarding your particular plan, please call your insurance carrier prior to your appointment. Also, please be ready to present a current insurance card to the receptionist once you arrive.

Feel free to contact our office at 334.836.1212 and speak to one of our insurance representatives for a complete list of medical providers.

HMO/PPO or Contracted Insurance Coverage

If you have insurance coverage through a company that we have contracted with, we require a copy of your insurance card, insurance mailing address, and payment of your deductible and/or co-pay at the time of service. You will also be responsible for making sure that we have received an appropriate referral. Failure to provide any of the items mentioned may require you to pay at the time of service.

Medicaid

Our physicians are participating Medicare providers. Office visits and procedures by a doctor are covered under part B of the Medicare program. Medicare pays 80% of their allowable charges after you pay your annual deductible for the calendar year. If you have supplemental insurance, we require a copy of your insurance card and insurance mailing address.

By reading the following and signing a copy of the Financial Policy, you agree to have read all the information above and agree that, regardless of any insurance status, you are ultimately responsible for the balance on your account for any professional services rendered.

In the event that your insurance company is billed, you also authorize payment of medical benefits to be paid directly to Digestive Health Specialists of the Southeast. A photocopy of this agreement shall be considered as effective and valid as the original.

In the event that your account is placed with a collection agency or an attorney upon default of payment, you agree to pay all collection costs including attorney fees and court costs.

Assignment of Benefits

For services received, you hereby authorize and direct that payment(s) made directly to Digestive Health Specialists of the Southeast for benefits payable under the terms of your policy. You recognize that if payment is made directly to you, the amount received up to the amount due for services rendered is the property of Digestive Health Specialists of the Southeast and should be paid over to Digestive Specialists of the Southeast immediately. You understand that you are financially responsible for charges not paid by this assignment.

Authorization of Release of Medical Records

You authorize Digestive Health Specialists of the Southeast to release all medical records and pertinent medical information to any insurer, governmental agency providing benefits, referring or consulting physicians, or to anyone liable for charges.

Financial Responsibility

You certify that the information given is complete and accurate. You agree to pay Digestive Health Specialists of the Southeast for any and all charges for services rendered. You understand that Digestive Health Specialists of the Southeast will attempt to collect said assigned insurance benefits for a period from 30 to 60 days after the date of services at which time payment of the full amount due will be your responsibility. In the event that payment is not made timely, you realize that Digestive Health Specialists of the Southeast may contract the services of a collection agency, credit bureau, or an attorney to expedite collections of the balances due. You also agree to then pay all collection costs including attorney fees.