Patient Financial Policy

Thank you for choosing Florida Woman Care of Jacksonville as your health care provider. We are committed to providing you with exemplary care. Your understanding of our Patient Financial Policy is an important component of our relationship.

If you need further information or have any questions, please ask to speak with a member of our team.

Responsibility for Payment of Medical Services

It is your responsibility to notify our office promptly of any patient information changes (i.e., address, name, insurance information) to facilitate appropriate billing for the services rendered to you. If you have insurance, please bring a current copy of your insurance card with you to your visit.

Insurance Claims

As a courtesy to you, we will file a claim with your insurance company after your visit. By signing this form, you agree to allow us to file a claim with your insurance company on your behalf and receive the payment directly.

Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. You agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are not in network with your insurance company and your insurance pays you directly, you are responsible to submit payment to us upon receipt.

The amounts due that will be your responsibility may include amounts attributed to deductibles, co-pays and other out of pocket maximums that are defined by your insurance policy. We are not privy to the amounts you may have paid towards these amounts and therefore have no ability to estimate or advise as to how much you may owe under these sections of your health insurance policy. If you are concerned about these amounts, please contact your insurance company directly to determine what amounts are due according to the policy. Please see the “Assignment of Benefits” form provided for your signature which further explains your obligations.

Please familiarize yourself with the policies, procedures, and benefits of your insurance plan (including the rules regarding pre-authorizations and referrals). We cannot guarantee that your insurance plan will cover charges for your visit, and any balance due for services is your responsibility. Remember your insurance is a contract between you and the insurance company.

Patient Responsibility

When applicable, all copayments, deductibles, patient responsibility amounts, and past-due balances are due at the time of service. Unless previous arrangements have been made with our office staff, you will be responsible for paying the full amount at your visit.

By signing this form, you are guaranteeing all charges incurred for services rendered by the practice and its provider(s), including other affiliated services which may include but are not limited to laboratory, imaging and other ancillary services, shall be paid in full.

Failure to make payments in a timely manner towards any balance or payment arrangement may result in your account being sent to collections. If your account is sent to a collection agency, you may be responsible for all fees for collections purposes by the agency. We reserve the right to not schedule future appointments or termination of care from our practice for non-payment.

There may be times that a credit may develop on your patient account. You agree that the practice may apply such credit to any outstanding patient balance that may exist or any affiliate of the practice that provided professional services to you. If an outstanding balance does not exist, this credit will be refunded to you.

Payment Options

We accept multiple forms of payment. Payments can be made in the office, or through your Patient Portal.

For your convenience, we may maintain a record of your credit card, to allow the practice to charge your credit card on-file for any amount not covered by insurance, up to the maximum charge amount set in your agreement, for all services provided. See the Card on File Agreement terms for additional information.

If you are experiencing financial difficulties and need to make special payment arrangements, please ask to speak with a member of our staff.

If you are pregnant or scheduled for surgery, we may discuss a pre-payment plan option with you for these services.

Missed Appointments

We reserve the right to assess a No-Show Fee for failing to cancel an appointment in a timely manner. The applicable fee will be applied to your patient account.

Multiple “No-Shows” may result in termination from the practice and/or any Care Center within our affiliated network of providers.

Additional Fees

You may incur additional fees from the office providing any of these services. Please check directly with the practice for the charges associated with each request.

• If your insurance company or employer requires us to complete disability forms, including FMLA forms
• Copies of Medical Records
• Non-Sufficient Fund Fee for Dishonored Checks

You may also receive bills from third party organizations, such as laboratories, who provide services to you. These charges should be discussed directly with the third-party organization from which the fees may be received from.

Facility and unaffiliated provider fees, such as a hospital, surgery center or anesthesia services, will be billed separately from services rendered by your provider in our practice.

Self-Pay Patients

Patients who do not have insurance or if we are not contracted with your health plan may be provided with a discounted self-pay fee structure. Payment is expected to be made at the time services are rendered.

If you are unable to pay in full on the day of your appointment, please work with our office staff to make payment arrangements in advance of your appointment.

Good Faith Estimates

Under the No Surprises Act (NSA), uninsured patients and commercially insured patients who choose not to use their benefits will receive a good faith estimate (GFE) of charges from providers before scheduled services. This estimate, utilizing the self-pay discount will be provided within one business day of a service being scheduled or a GFE requested.

Billing & Statements

You will receive an itemized billing statement listing each service and associated charge you have been billed for. Payment is due upon receipt. Your account will be considered past-due 30 days from the date of the first statement. Generally, our billing statements are sent out every 25 days.

Release of Billing Information

I hereby authorize the release of any and all information required to collect and process any claims for reimbursement of charges incurred for services rendered to me by you or any member of the provider group.