Your signature at the end of this document will indicate that you have read, understand and agree to the policies outlines below.
As of November 2015, Marina Medical requires a valid credit card be kept on file.
This policy is designed to help you avoid all billing related fees, streamline the billing process in our office and eliminate the expenses related to handling statements, overdue accounts, and focus our time and energy on providing medical care.
The card information is stored electronically in an encrypted form and cannot be viewed by our office staff. Your signature will authorize the card to be used for payment of your co-insurance, co-pay, deductibles and uninsured amounts.
How the policy works:
1. At the time of registration or check-in, you will be asked for your credit card information to be electronically stored in encrypted form in our credit card system. Only the last four digits are visible to our staff.
2. We will discuss with you at each visit the estimated amount of your patient responsibility. Your card will be charged on the day of your visit, unless you provide other means of payment. Cash and checks (with restrictions) can also be accepted. You will be asked to sign your credit card receipt as always and will be provided with a copy of the receipt.
3. If applicable, we will bill your insurance carrier as a courtesy for all charges related to the visit.
4. When we receive an explanation of benefits (EOB) from your insurance, we will apply the portion paid at the time of service. If there is an unpaid balance, your card will be charged on receipt of the insurance EOB or per instructions you have provided.
5. In the event of a declined charge, you will be asked for a new credit card number and/or payment before continuing care. If your credit card is declined more than once and payment remains unresolved, Marina Medical may place other restrictions on your account.
6. We will maintain a clear record of all payments and charges. However in the rare case that an overpayment occurs, your account will be credited for use on upcoming visits. If the balance is zero and you have taken a break from therapy, a reimbursement can be put back on the same credit card.
7. If the credit card information we have on file changes for any reason, you must notify Marina Medical immediately, or update your credit card information in your patient portal.
I have read and understand the credit card policy and agree to abide by its guidelines.
SIGNATURE OF PATIENT OR RESPONSIBLE PARTY.
Please enter todays date.
