It is important for you to be aware that our professional services are rendered and charged to you, not to the insurance company. You will receive a bill from our office. We will expect prompt payment from you. If we do not receive payment from you for three consecutive billings, we will turn your account over to a collection agency.
If you need to make arrangements for payment, you must discuss this with the business office.
Co-pays are due at the time of service.
A NO SHOW FEE will be charged to your account if you fail to cancel your appointment 1(one) hour prior
The Federal Trade Commission issued a set of regulations, known as the “Red Flag Rule”, 12 CFR Section 114 of the FACT Act. It is the policy of Gunnison Valley Family Physicians to follow all Federal and State laws and reporting requirements regarding identity theft. Therefore it is our policy to verify patient identity, address, and insurance coverage at the time of patient registration/check-in.
I certify that I have read and understand the above and agree that I am financially responsible for all charges whether or not paid by insurance. I also understand that if my account becomes past due and is turned over for collection, I will also be responsible for any collection fees required to secure this obligation.