Office and Financial Policies

    Thank you for reviewing the following office and financial policies. We commit to put forward our best efforts to provide you with the most up to date, skilled, and compassionate health care possible. We also agree to:

    • Provide you and/or your insurance company with a timely and accurate statement of all charges for services rendered.

    • Explain fully all charges for services rendered and acceptable payment methods.

    • Secure all pre-authorizations and/or referrals that your health insurance plan requires us to obtain for your ongoing care or treatment.

    In return we respectfully ask you to agree to the following:

    • All appointments must be cancelled 24 hours prior to your scheduled appointment. Failure to cancel within this time frame will result in a charge to your account. If you are an established patient a $35.00 fee will be charged to your account. If you are a new patient or are scheduled for a procedure, a $100.00 fee will be charged to your account. If you are a patient scheduled for a laser procedure, a $200.00 fee will be charged to your account.

    • If you are a patient who requires an in-person interpreter, you will be responsible for the full fee for the interpreter if you no show your appointment or fail to cancel with greater than 24 hours’ notice.

    • If you are more than 15 minutes late for a medical appointment, you may be asked to reschedule or to see a different provider.

    • It is your responsibility to inform us of any changes to your account, such as phone number, insurance, or address change. If you do not provide us with the correct information and we are unable to receive payment as a result, you will be responsible for the balance.

    • As a courtesy to you, we file your insurance claim for you. If your insurance is inactive or does not cover the services provided, you will be responsible for payment. Any balances older than 90 days, which have not been paid by your insurance company, may be billed for you. Any balances remaining after your insurance has paid will be due on receipt of a statement from our office. If your payment is not received within 60 days your account may be referred to a collection agency.

    • It is your responsibility to confirm with your insurance if we are in or out of network, and if the services you request are covered by your insurance.

    • All co-pay, co-insurance and deductibles must be paid at the time of service. If you are having a baby, surgery, or being admitted to the hospital, we will collect your deductible before your delivery or procedure.

    • Any accounts with outstanding balances must be paid prior to any additional services being rendered.

    • A $25.00 charge will be charged for any returned checks. Checks will be processed electronically.

    • For your personal use, there is a $35.00 charge for your medical records, unless requested by another physician.

    • If you require a short term disability, FMLA or other forms to be filled out by us, these forms will be completed for a fee of $35.00

    • As a convenience to our patients, we provide a blood draw station in our office for LabCorp, Quest, MHDL, MDL, Progenity and Natera. Charges for most lab tests, including pap smears, are not included in the charges from our office and are billed separately by each lab company. These charges are NOT included in your regular statements from Aurora Gonzalez MD and Associates (unless you are an un-insured patient). It is your responsibility to understand your insurance benefits for lab work.

    • For all services rendered to minor patients, we will look to the adult accompanying the patient and/or the parent or guardian with custody for payment.

    • Our office prefers to use email to notify patients of lab results, reminders and other important office information. Please allow 2 weeks to receive notification of your lab or test results. I understand that this office cannot be responsible for information loss or delays that are due to technical factors beyond this office’s control.

    Please clearly print your preferred email address below if you consent to using email for these preferred communications:

    I have read and understand the above office and financial policies and agree to be bound by these terms. I also understand and agree that Aurora Gonzalez MD and Associates may amend such terms from time to time. I have received /read a copy of the HIPAA statement.