Gordon Medical accepts cash and credit cards for payment. No personal checks.
No Insurance/Non-Contracted Insurance: If you have no insurance, we expect you to pay for your visit at the time of service. Non-contracted insurance will be billed if appropriate insurance information is given; however, payment will be expected at the time of service. $150 for new patients and $75 for established patients.
Medicare: We are a participating provider for the Medicare program. We will submit your claim/service to Medicare. If you have secondary or supplemental insurance, we will submit after payment from Medicare; however, we must have a copy of your card and the appropriate information.
Medicaid and Medicaid HMO: We participate with the Medicaid program. You must provide us with a copy of your Medicaid card indicating that you are eligible for Medicaid at the time of service. Should services be rendered and you are no longer eligible for Medicaid coverage, you will be responsible for payment based on our normal fee schedule. All co-pays are to be paid on the day of the service to include a $2 office co-pay and $1 lab co-pay.
Contracted Insurance (HMO, PPO, EPO, POS): If you have insurance we are contracted with, we submit your insurance claims for you if you supply us with the necessary information. This includes a copy of your card, the address to submit claims and a telephone number to allow us to verify coverage. You are responsible for payment of your co-pay at the time of service and any amounts not covered by your insurance, including the deductible. If your coverage is denied for any reason, you are responsible for payment of the entire balance due based on our normal fee schedule.
Workers’ Compensation: We do NOT accept Workers’ Compensation insurance. You will need to find another provider.
Auto Accidents: We do NOT accept Auto Accident insurance. You will need to find another provider.
Ancillary Services: We try to arrange for labs, radiology and any other testing to be provided at a facility which participates with your insurance. However, with the constantly changing insurance contracts and plans, we are not always aware of changes made to these participation lists. As the patient, please notify us of any concerns as to your insurance. It is your responsibility to know with what facilities your insurance participates.
Referrals and Authorizations: We attempt to assist with referrals and authorizations; however, it is ultimately your responsibility to obtain any referrals or authorizations for visits, procedures, testing or any other service provided or ordered by Gorman Medical providers. Should your insurance deny payment for no referral, no authorization, or not medically necessary procedures, you will be deemed financially responsible for all services rendered at Gorman Medical, P.C.
No Show Fees and Missed Appointments: When we schedule your appointment, this is your time that has been reserved with the doctor. We cannot fill that space if you do not notify us in advance of your inability to make the appointment.
To avoid any fees, we request a 24-hour notice. We charge $50 for a missed office visit, $25 for a missed script pick-up, $150 for a missed injection procedure and $85 for a missed EMG procedure.
The fees for late cancel of an appointment (within the 24-hour time frame) are: $25 for a missed office visit, $0 for a missed script pick-up, $75 for a missed injection procedure and $35 for a missed EMG procedure.
You are responsible to pay within 30 days of the missed appointment.
Assignment of Benefits and Authorization to Release Information: I hereby assign my Medicare and/or any other insurance benefits to which I am entitled. I authorize and direct my insurance carriers(s) including private insurance, and other health /medical plan to issue payment check(s) directly to Gorman Medical, P.C. for services rendered to me or my dependents regardless of my insurance benefits, if any.
I authorize Gorman Medical, P.C. to furnish and/or release any information necessary to insurance carriers concerning my illness or treatment to process my insurance claims and a photocopy of my signature can be used to process my insurance claim for the period of a lifetime. This order will remain in effect until revoked in writing.
I have requested medical services from Gorman Medical, P.C. on behalf of my dependents or myself and I understand that by making this request, I become fully responsible for all charges incurred during authorized treatment. I further understand that fees are due and payable on the date that services are rendered and agree to pay all charges incurred immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
I will be responsible not only for the charges incurred but also any costs involved in collection of my account. These include but are not to be limited to interest charges, re-billing fees, court costs, attorney fees, and collection costs. In the event my account becomes delinquent and turned to collection agency or attorney due to non-payment, that I will pay an additional 33.3 % of the balance as reasonable collection fees (to be added to the balance at the time the account is placed for collections) plus any court costs and attorney’s fees incurred in connection with the collection account.
Insurance coverage is a matter between my insurance company and myself. I am ultimately responsible for the payment of my account.