Financial Policy

It is the goal of Carolina Ear and Hearing Clinic to provide you with the finest of medical care available at a cost that is both fair and reasonable. Your understanding of our financial policy is essential.

The following is our Financial Policy, which we require that you read and sign prior to treatment:

• Self-pay patients are expected to pay for services received in full at the time of service. Any financial arrangements must be made before you see the physician.
• We cannot file your insurance if you do not have a copy of your insurance card or the necessary insurance information. Without a copy of your insurance card, we must have the insurance company’s name, phone number to verify benefits, policyholder’s name, date of birth, and insurance identification number. Without this information, your account will be treated as self pay. (see above)
• If your health plan requires a referral or authorization from your primary care physician, we will need to receive the authorization before you see our physician. If we have not received an authorization prior to your arrival at our office, we have a telephone available in our waiting room for you to call your primary care physician or health plan to get it. If you are unable to obtain the referral at that time, you can sign a medical wavier and pay us directly for the services we provide you. We will refund you when we receive the proper authorization for those services.
• As a courtesy to you, we will file charges with your insurance company. Charges not paid by your insurance company within 90 days will become due and payable by you unless you have Medicare or Medicaid.
• All co-payment, co-insurance, and deductible amounts are due at the time of service and prior to your scheduled surgery. We accept cash, check, Visa, MasterCard, and American Express.
• The responsibility for payment of services rendered to dependent children whose parents are divorced rests with the parent seeking treatment. Any court ordered responsibility judgment must be determined between the individuals involved and cannot be considered by this office.
• In the event your health insurance determines a service to be "not covered", you will be responsible for payment. We try to inform patients when services may not be covered; however, it is the patient’s responsibility to understand his/her policy limitations.
• In order for us to accept and file Medicaid we must have a CURRENT Medicaid card on file for each visit. Carolina Access requires an authorization from your Primary care Physician. Without this information you will be considered self-pay and Medicaid will allow us to collect from you at the time services are rendered.
• We will bill for workers compensation services that have been pre-authorized by your employer or workers comp insurance carrier. You will receive a monthly statement from this office to keep you informed. After 90 days, these charges become your responsibility.
• Copying medical records: You will need to request in writing and pay a reasonable copying fee if you want to have copies of your medical records. Please allow a minimum of two weeks for copies to be ready.
• A $25 service charge will be applied to your account for any returned check. If a check has been returned, we will only accept cash, Visa, MasterCard, and American Express.
• We understand that from time to time cancellations and rescheduling appointments occur. Please allow our office at least 24 hour notice for cancellations and rescheduled appointments. Failure to do so 3 consecutive times will result in a no show fee of $25.00.

Please be aware that any unpaid balance over 90 days is subject to intensive collection procedures.

Effective Date: Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force.

Print a copy of the Financial Policy