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Financial Policy

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Alpine Allergy & Asthma Associates, Inc. Financial Policy

January 1, 2010

We are dedicated to providing the best possible care for our patients and want you to completely understand our financial policies.

Payment for co-pays, deductibles and non-covered/cosmetic services are due at the time of your appointment.

If we are not contracted with your insurance or you have no insurance, you are responsible for payment in full at the time of service. Due to strict insurance billing time limits, patients who do not bring their insurance cards to their appointments will be considered cash patients.. Patients with JSA (Health Savings Accounts) are responsible for payment at the time of service.. An itemized receipt will be provided for patients to receive reimbursement from their HSA.

We accept the following credit cards:. Visa and Master Card

There is a $35.00 charge for returned checks.

There may be a $35.00 cancellation fee for missed appointments.

Your insurance policy is basically a contract between you and your insurance company.. We will file a claim to your insurance company for services provided and bill you for remaining balances.. In the event of insurance non-payment, you are responsible for charges in full.. Payment is due upon receipt of a statement from our office.

Please contact our billing office if you have any questions or concerns.

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I have read and understand the financial policy of Alpine Allergy & Asthma Associates, Inc.

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Signature of patient/responsible party........................... Date

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