Finical Policy Form Specialists & Anesthesiologist in Twin Falls

You are financially responsible for the medical services you receive at Southern Idaho Pain Institute (SIPI). Please review our policies below and sign at the end to indicate your agreement to these terms.

APPOINTMENTS Copayments: Copayments for clinic visits are due at the time of service. If you are unable to make your copayment at the time of service, SIPI reserves the right to reschedule your appointment until a time that you are able to make your copayment. Payment for any outstanding balance is due at your appointment.

Procedure Prepayment: SIPI collects your payment for a procedure at the time when the procedure is scheduled. Your prepayment is based on an estimate of your expected financial responsibility.
This is an estimate only. You are responsible for any unpaid balance after your insurance (if applicable) has been billed. In the event of over-payment, you may request a refund according to our refund policy, below. We reserve the right to reschedule your procedure until prepayment has been made. When receiving a procedure in our facility, SIPI Ambulatory Surgery Center, you will receive a bill for the professional charges and the facility charges. What this means to you is there will be 2 charges for a procedure, you are not being double billed.
Missed Appointment or Cancelations: Made Without 24 hr. Notice & Late Arrivals. If you are late by 15 minutes or more, we may reschedule your appointment. If you are more than 60 minutes late, or if you do not show up to your appointment, you will be responsible for a missed appointment fee.
Missed office visit appointments are subject to a $20 charge. Missed procedure (surgery) appointments are subject to a $50 charge. These fees are also applicable to cancelations made without 24 hr. notice. These charges are your responsibility and will not be billed to any insurance carrier.

INSURANCE PAYMENTS
Financial Responsibility: Your insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment-in-full for all medical services provided to you. Any charges not paid by your insurer will be your responsibility, except as limited by our contract (if any) with your insurance carrier.

Coverage Charges and Timely Submission: It is your responsibility to inform us in a timely manner of any changes to your billing or insurance information. There is a time limit within which SIPI must submit a claim on your behalf to your insurer. If SIPI is unable to submit your claim within this period because we have not been supplied with your correct insurance information, you will be responsible for the charges.

Self-Pay: If you do not have health insurance, or if your health insurance will not pay for services rendered by SIPI, you are considered a self-pay patient. Your charges will be based on our current self-pay fee schedule (available from our front desks). Self-pay patients are required to make payment in full at the time of service.

BENEFITS AND AUTHORIZATION
Insurance Plan Participation: We participate in many but not all insurance plans. It is your responsibility to contact your insurance company to verify that your assigned physician participates in your plan. Out of network charges may have higher deductibles and copayments.

Referrals: Referral and prior authorization requirements vary widely among insurance carriers and plans. If your insurance carrier requires a referral for you to be seen by SIPI, it is your responsibility to be aware of this fact, and to obtain this referral.

Prior Authorization and Non-Covered: SIPI may provide services that insurance plans exclude or require prior authorization. If insured, it is ultimately your responsibility to ensure that services provided to you are covered benefits and authorized by your insurer. SIPI, as a courtesy to our patients, makes a good faith effort to determine if services we organized are covered by your insurance plan, and, if so, whether or not prior authorization for treatment is required. If we determine that a prior authorization is required, we will attempt to obtain such authorization on your behalf. Out of Network Payments: If we are not part of your insurance carrier’s network (out-of-network) and your insurance carrier pays you directly, you are solely responsible for payment and agree to forward payment to SIPI, immediately.

ACCOUNT BALANCES AND PAYMENTS
Reassignment of Balances: If your insurance company does not pay within a reasonable time, we may transfer the balance to your sole responsibility. Please follow up with your insurance carrier to resolve non-payment issues. Balance is due within 30 days of receiving a statement.
Collection of Unpaid Accounts:
If you have an outstanding balance over 120 days old and have failed to make payment arrangements (or become delinquent on an existing payment plan), we may turn your balance over to a collection agency and/or an attorney, which may result in reporting to credit bureaus and/or legal action.
SIPI reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You agree to pay SIPI for any expenses we incur to collect on your account, including reasonable attorneys’ fees and collection costs.
Returned Checks:
Returned checks will be subject to a $25 returned check fee. Refunds: Refunds for overpayment or prepayment on cancelled procedures are made only after there has been full insurance reimbursement for all medical services on your account. Please submit a written refund request, allow four to six weeks for your request to be processed. Send requests to: SIPI, Attn: Billing Department, 176 Falls Ave, Twin Falls ID 83301-3115. Statements. Charges shown on statement are agreed to be correct and reasonable unless protested in writing within thirty (30) days of the billing dates.

This is to certify that on ___/___/_____ I was offered verbal and written notice of Southern Idaho Pain Institute’s privacy policy and Patient Rights in accordance with SIPI’s IIHI (Individually Identifiable Health Information) compliance manual and Federal Law. I understand that SIPI may change their privacy policy without notice and I will be made aware of any updates as they occur. I understand that at any time I may request a copy of the current policy. I was also offered Advanced Directive documents and verbal communication on my Advanced Directive wishes which SIPI will abide by. A copy of this signed document verifying receipt of the policies will be kept in my permanent medical record.