1101 Reed Avenue, Suite 300, Wyomissing, PA 19610 (610) 374-4401
Thank you for choosing Digestive Disease Associates, Ltd. (DDA). DDA is committed to providing you with the best care possible, while minimizing your out of pocket expenses and making the payment of your balance as easy as possible. In order to do this, our financial department will need your assistance and your understanding of our financial policy. Please read and sign this Financial Policy prior to your appointment.
INSURANCE: For your convenience we will be happy to submit claims to your insurance company for payment, provided we are contracted with your chosen insurance. We will submit to primary, secondary and tertiary plans as needed.
It is your responsibility to provide DDA with current, accurate billing information at the time of check in and to notify us of any changes in the information. If the information given is inaccurate or inactive you will be considered self-pay.
Co-pays are due at the time services are rendered. This is a contractual agreement you have with your health plan and our contractual agreement with the health plan. If not paid at time of service there will be a $25 C
copay Billing Fee attached to the date of service. We accept cash, checks, Debit cards and all major Credit cards. Returned checks are subject to a $50 processing fee.
REFERRALS: It is your responsibility to determine if you require a referral before your appointment. If you arrive without a referral and one is needed, you may be asked to either pay for your appointment in full before being seen, or to reschedule your appointment.
PRE-AUTHORIZATIONS: DDA will obtain precertification for any services that require it; that does not guarantee that the claim will be covered or paid for by your insurance. Precertification is simply the process of notifying the insurance of certain treatment and services you will receive at DDA so they can determine medical necessity.
Please note: Our relationship is with you, not your insurance company. While pre-authorizations, referrals and the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility. Therefore, if you disagree with a bill from our office, your first step is to investigate the claim with your insurance company.
Not all services that we provide are guaranteed to be a covered benefit under all insurance plans. Please contact your insurance before any appointment to find out what their specific guidelines are for coverage.
SELF-PAY: You are expected to pay for your services at the time of the visit. If the visit is paid in full you will be eligible for a 20% discount. Discounts are not offered if your service is not paid in full. If you elect to pay your visit with multiple payments, it will be required that you pay a partial (or 1/3) payment at time of service and you will receive a statement for the remainder balance. Balances are required to be paid within 30 days of date of service. IF AT ANY TIME YOU ARE UNABLE TO PAY A BALANCE DUE, PLEASE CALL OUR OFFICE PROMPTLY TO MAKE A PAYMENT ARRANGEMENT. WE ARE HAPPY TO WORK WITH YOU.
BALANCES: You have a financial responsibility to pay for any services received at DDA. This includes Co-pays, Co-insurance, deductibles, non-covered services and self-pay portions. Please understand that three (3) statements will be sent prior to starting the process of sending your account to a collection agency. If your account is turned over to a collection agency a $75 service charge may be added to the balance.
Authorization, Assignment and Responsibility of Patient:
I hereby authorize Digestive Disease Associates, Ltd (DDA) to release to the insurance companies/carriers listed in my file any medical or other information required for processing insurance claims. I, Guarantor, assign all benefits for my treatment and medical services provided to me to be paid directly to DDA. I understand that I am financially responsible for any co-pays, co-insurance, deductibles, non-covered services, self-pay portions including copay billing fee, returned check fees, and all costs of collection and reasonable legal fees should collection become necessary. I have read and understand this Financial Policy and by signing I am in agreement and accept all terms and conditions described above.
Signature of Patient/Guarantor Date