By signing below, I (the patient) understand that I will be held financially responsible for all charges resulting from services provided. I authorize direct payment of medical benefits from my insurance company to Pioneer Physicians Network, Inc. In addition, I authorize release of any medical information necessary for reprocessing of these claims for payment including, but not limited to, facsimile transmission of information.
I consent to the use of my medical information necessary for transmission of prescriptions to the pharmacy and as needed for the coordination of formulary and/or benefits eligibility with my insurance provider. I consent to the query of my external prescription history as necessary to manage my healthcare and related services.
In accordance with the notices of privacy practices, I authorize the use and disclosure of any medical information with a third party to coordinate or manage my healthcare or any related services.
• Co-pays, deductibles and/or co-insurance are to be paid when you arrive at check-in. In accordance with your health insurance policy, your co-pay or other time of service responsibility payment is to be paid in full at the time of your office visit. We accept cash, personal checks, Visa, MasterCard, Discover and American Express. You may also use your HSA or debit card. *Please note that if you use your HSA card – refunds can only be returned to the HSA card and cannot be directly refunded to the patient or to the patient account.
• It is your responsibility to provide accurate and up-to-date insurance information promptly to ensure proper billing of your account. If we are unable to process your insurance claim due to delays in receiving the necessary information, you will be held responsible for any outstanding balances and will need to submit a claim for reimbursement directly with your insurance provider.
• If you are covered by a High Deductible Health Plan (HDHP): Health Reimbursement Account (HRA) and Health Savings Account (HSA), you will be required to pay a fee of $125 at the time of service if you have not met your deductible. Your required payment may be adjusted based on the level of services to be provided.
• If you do not have health insurance, payment must be made at the time of service. A driver’s license or other identification will be required for all self-pay accounts. Note: until insurance eligibility is verified, your account will remain as “self-pay” and you will be required to make payment at the time of service.
• Self-Pay Time of Service Discount: If your financial status is “self-pay” you are expected to pay in full at the time of service. For payment in full at the time of service, you will receive a 20% discount on all office-based services and a 40% discount on all laboratory services.
• Worker’s Compensation (BWC) claims require special processing. You will be required to complete BWC claims processing information at the time of service. If information is not provided, your account will remain as self-pay. Not all Pioneer Physicians are BWC providers. Please contact your office location and inquire. They will direct you to the proper location. This also includes ODOT physicals.
• Motor Vehicle Accident (MVA) will be considered self-pay and will require payment at the time of service as well as completion of a patient consent form. Pioneer Physicians will provide the necessary information to you regarding your MVA claims, however, will not process claims to your auto insurance carrier.
• We will ask you for payment on your outstanding balance when you arrive for your visit One-time statements are mailed out for balances under $20.00 If you do not receive a billing statement inquire with your office. Our office staff would be happy to provide you an itemized statement at your request.
• Your balance is due in full upon receipt of your monthly statement. This includes co-insurance, deductibles, and services not covered by your insurance policy and services billed to your insurance company but were denied for payment after repeated attempts by our billing department to resolve the disputed claim. You are responsible for working with your health insurance company should they request additional information from you for your claims to be paid.
• Returned checks: For each NSF check, our fee is $25.00. If we receive an NSF check, we will not accept another personal check from you until the NSF fees are paid and payment for the returned check has been made. If we receive two (2) returned checks on an account, we will no longer accept personal checks.
• Failure to make your payment in full, or as arranged, may result in your account being turned over to a collection agency. If your account is sent to collection, it may appear on your credit report. Your healthcare services relationship with Pioneer Physicians Network may be impacted as our policy is to dismiss patients and their families that have been sent to collections from all physicians and ongoing services of the practices.
• Refund Checks: Patient/Guarantor credits will be refunded unless there is an upcoming appointment or open insurance claim that we can apply the credit.
• We will work with you in every possible way to resolve any discrepancies with your account and/or to make acceptable payment arrangements when you contact us for assistance. If you have any questions and/or feel you are not receiving the service you should, please contact our billing department at 330-974-0788. Pioneer Physicians Network billing services are located in the administrative office in Uniontown, Ohio.
• No Show Fee: We will provide you with a courtesy call to remind you of your appointment. Please note that a $50 no-show fee will be charged if you fail to attend your appointment without providing at least 24 hours' notice.
I have read and understand the Pioneer Physicians Network Financial and Annual Patient Consent for Release of Information and Medical Claims Processing Policy. I agree to assign insurance benefits to Pioneer Physicians Network whenever necessary.