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JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the

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Page 1: JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the
Page 2: JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the
Page 3: JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the

350 CONGRESS PARKWAY, SUITE E, CRYSTAL LAKE, ILLINOIS 60014

27750 WEST HIGHWAY 22, SUITE 105, BARRINGTON, ILLINOIS 60010 PHONE 815-477-8900 FAX 815-477-7160

RAJA SHARMA, MD, FACC, FSCAI JOEL D. ROBBINS, MD, FACC, FSCAI

JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC

IllinoisCardiovascularSpecialistsFinancialPolicy

ThankyouforchoosingGlobalCareS.C.(dbaIllinoisCardiovascularSpecialists)asyourhealthcareprovider.Weknowyouhaveachoicewhenchoosingyourmedicalproviderandhopethatwemeetyourexpectations.Aclearunderstandingofourpatientfinancialpolicyisimportanttoourprofessional

relationship.Pleaseunderstandthatpaymentforservicesispartofthatrelationship.Pleaseaskusifyouhaveanyquestionsaboutourfees,policies,oryourresponsibilities.Itisyourresponsibilitytonotifytheofficeofanypatientinformationchangessuchasaddresschanges,namechangesorchangesin

insuranceproviders.

Co-PaysThepatientisexpectedtopresentaninsurancecardateachvisit.Allcopaymentsmustbepaidatthetimeofservice.Therewillbenoexceptionsforthis.Ifacopaymentcannotbemadeourprovider

cannotseeyouthatday.

Self-paypatientsSelf-paypatientswillberequiredtopay$250foranyinitialconsultationand$175dollarsforanysubsequentvisits.Anyremainingbalancewillbebilledtothepatient.

Referralsandpre-authorizationsDuetothemanychangesininsurancepoliciesitisnolongeraneasy

tasktointerpreteachindividualpolicy.Itisyourresponsibilitytoknowyourindividualpolicy.CertainhealthinsurancessuchasHMOsrequirethatyouobtainreferralfromyourprimarycareproviderbeforevisitingaspecialist.IfyourInsurancecompanyrequiresareferral,youareresponsibleforobtainingit.

Failuretoobtainareferralcouldresultinthepatientbeingresponsibleforallcostsincurred.Wewillbeunabletoseeyouifyoudonotproperlyobtainareferral.Pre-authorizationwillbeobtainedbyourofficeforanytestingorderedbyourphysicians.Understandthatpre-authorizationisnotaguaranteeof

payment.Youareultimatelyresponsibleforpaymentofservicesrenderedifyourinsurancecarrierdoesnotpayforanyreason.

PaymentbalancesInordertoprovideahighlevelofserviceandtocontinuetorunourindependentpracticeweexpectfull

paymentatthetimeofservice.WeacceptmanyinsuranceplanscurrentlyofferedintheChicagoArea.Itisourresponsibilitytoaccuratelyandquicklybillyourinsuranceprovider(s)onyourbehalf.

Ifapatients’balanceafterinsuranceremittanceis$250orless,weexpectfullpaymentwithin30daysofsendingyouabillingstatement.Ifapatients’balanceafterinsuranceremittanceisgreaterthan$250

weexpectatleasta$250paymentwithin30daysofyourbillingstatement.Anyremandingbalancewill

Page 4: JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the

350 CONGRESS PARKWAY, SUITE E, CRYSTAL LAKE, ILLINOIS 60014

27750 WEST HIGHWAY 22, SUITE 105, BARRINGTON, ILLINOIS 60010 PHONE 815-477-8900 FAX 815-477-7160

RAJA SHARMA, MD, FACC, FSCAI JOEL D. ROBBINS, MD, FACC, FSCAI

JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC

beexpectedtobepaidoffinfullwithin6monthsofthefirstbillingstatement.Wewillrequireavalid

creditcardonfileandyourcardwillbechargedmonthly,afterthefirst3monthsbalancesthathavenotbeenpaidinfullwillincuramonthlynon-adjustableservicechargeof$20.Accountsnotpaidinfullafter6monthswillbeturnedovertoalicensedcollectionagencyandwillbesubjecttoanyapplicable

placementfees.Atthatpointthepatientmostlikelywillbedischargedfromthepractice.

MissedappointmentsIllinoisCardiovascularSpecialistrequires24-hournoticeofappointmentcancellation.Appointmentsmissedandnotpreviouslycanceledmaybechargedafeeof$50.00.

Returnedchecks

Thechargeforreturncheckis$35dollarspayablebycashormoneyorder.Thiswillbeappliedtoyouraccountinadditiontotheinsufficientfundsamount.Youmaybeplacedonacashonlybasisfollowinganyreturnedcheck

Thisfinancialpolicyhelpstheofficeprovidequalitycaretoourvaluedpatients.Ifyouhaveany

questionsorneedclarificationofanyoftheabovepolicies,pleasecontactoraskus.

Fees:

Cancellation/Reschedulelessthan24hrs$50.00

Noshowforappt$50.00

Lexiscan/MyoviewStresstestCancelationlesstan24hrs/useofCaffeine$250.00

Returncheckfee$35.00

FMLA/Disabilityforms/workreleasePaperwork/Forms$50.00

MedicalRecordsBaseduponIllinoisStateGuidelines

____________________________________________________________________

(Patient/GuardianSignature)Date

Page 5: JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the