The doctors and staff of Gastroenterology Consultants, CFL, PA would like to welcome you to our practice.
We strive to provide you with excellent medical care and our goal is to make your visit as convenient as possible.
We ask for help by understanding and cooperating with our financial policy.
Please read this policy and sign below confirming you understand the following:
All payments - Self pay fee, insurance co-payments, co-insurances and deductibles will be collected at the time of service.
Payable by Cash, Check, Visa, MasterCard, Discover or American Express.
A return check will result in a $25 service charge and all future payments will be required in the form of Cash
or Credit Card.
If you do NOT have your payment; your appointment may be re-scheduled
Payment in full of any past due balance is expected prior to being seen.
Our practice participates with several insurance companies; it is your responsibility to understand the requirements
and covered benefits of your plan.
You are responsible for any non-covered and/ or denied claim; you will receive a statement of
denied charges and payment is due in 30 days after the date of statement.
If you insurance policy requires a referral, it is your responsibility to contact your primary care physician
and have a referral faxed to our office prior to appointment date.
It is your responsibility to notify our office of any changes to your insurance coverage, your address and telephone number
You are required to cancel your appointment 24 hours prior to the appointment time.
No shows and late cancellation are subject to a $50 cancellation charge for office visits and $100 cancellation charge for procedures.
We realize that temporary financial problems may affect timely payment of accounts. If such problem arise, we urge you to contact us promptly for assistance in the management of your account. Call 407292-1414.
I have read and understand the above financial policy and agree to meet all financial obligations.
I hereby authorize direct payment of surgical/ medical benefits to Gastroenterology Consultants, for services
rendered by him/her in person or under his/her supervision. | understand that | am financially responsible for
any balance not covered by my insurance/s.
Espajiol: Por la presente autorizo el pago directo de beneficios medicos / procedimiento a Gastroenterology
Consultants, por los servicios prestados por el / ella en persona o bajo su / su supervisidn. Entiendo que soy
financieramente responsable de cualquier saldo no cubierto por mi seguro.
I hereby authorize Gastroenterology Consultants to release any medical or incidental information that may be
necessary for either medical care or in processing applications for financial benefits.
Espaiiol: Por la presente autorizo Gastroenterology Consultants para liberar cualquier informacien medica 0
incidental que pueda ser necesario, ya sea para la atencien medica 0 en la tramitacien de solicitudes de
| certify that the information given by me in applying for payment is correct. | authorize release of all records
on request. | request that payment of authorized benefits be made on my behalf.
Espaiiol: Certifico que la informacidn dada por mi en la solicitud de pago es correcta. Autorizo la liberacien de
todos los registros a peticien. Solicito que el pago de los beneficios autorizados se haga en mi nombre.