DAKOTA CHILD AND FAMILY CLINIC
FINANCIAL POLICY 2020
Dakota Child and Family Clinic (DCFC) must have complete and accurate information about you/your child in order to provide you with the most appropriate care, including processing your insurance claims. You must provide a driver’s license, government ID card or other official identification at every visit in addition to your insurance card(s) if applicable.
You will be asked to review your registration to ensure accuracy of all personal information. Please read and review this information carefully. Report any changes in address, insurance, e-mail and/or telephone number immediately.
You will be asked to sign an Assignment of Benefits form which allows us to bill your insurance company and receive payments directly from the insurance company. If you do not sign this form we hold the right to consider you to be self-pay and may ask you to pay cash at the time of your visit.
YOUR FINANCIAL RESPONSIBILITY
We rely on you to promptly pay your bills. You are ultimately responsible for all fees related to you/your child’s care. Any court ordered responsibility judgment is determined between the individuals involved, not the clinic. Unless we are provided with court documents, we hold the presenting parent financially responsible for paying for the services.
We will send you an itemized statement each month. PAYMENT IS DUE UPON RECEIPT of the statement. We accept cash, check, credit card (Visa, Mastercard, American Express, and Discover) or HSA debit cards. Outstanding balances will be referred to collection after 120 days. You may also be held financially responsible for any collection fees, up to 35% of the amount owed to Dakota Child and Family Clinic.
PAYMENT OF SERVICES OF LABORATORY CENTERS, IMAGING CENTERS OR SPECIALISTS OUTSIDE OF DCFC
DCFC has contracted with LabCorp for tests that cannot be completed by our laboratory. Bills for services you have received from laboratories, imaging centers or other specialty groups outside of DCFC are not processed by DCFC. If you have questions or concerns regarding bills for services provided by facilities other than Dakota Child and Family Clinic, please contact that facility.
All co-payments are due when you check-in for your visit. If you are unsure of your co-pay responsibilities, please contact your insurance company prior to your visit. We may request that you reschedule your appointment if you are unable to pay your copay at the time of check-in. You are responsible for paying your deductible and coinsurance as determined by your insurance policy.
We know that payment for your healthcare may be difficult and we will consider reasonable payment plans, provided you contact the clinic and make arrangements for payment upon receipt of your bill. In general, the payment plan may extend for three months, during which you will be responsible for regular payments. Please call our office if you would like to make arrangements for a payment plan.
We provide services to persons who do not have health insurance, however, you must notify us prior to your visit so we can accurately estimate your costs. A sliding fees scale is available for those who are eligible. Determining eligibility for our sliding fee scale can take up to two weeks. Reduced service fees cannot be applied until an eligibility determination is made. For more information and/or to pick up an applicatation please see our receptionist. MINIMUM PAYMENTS FOR SLIDING FEES ARE DUE AT THE TIME OF SERVICE.
IF you do not have insurance or your insurance company does not cover your services, we require a payment of $50.00 for an urgent/sick visit. Payment for these services is required at check-in. If additional services are deemed necessary by the provider, during your examination, the fees for these services will be discussed with you prior to completing the services. You are expected to pay the fees for additional services at the time of your visit. Any services provided by a reference laboratory, imaging facility or pharmacy will be billed to you according to that facility’s policy and are not billed by DCFC. It is your responsibility to contact outside providers (labs, imaging, etc.) for concerns you may have regarding their bills. We will make every effort to provide an estimate of outside services fees, if needed.
If you have any questions regarding treatment or service fees, please discuss them with us promptly and frankly. We will make every effort to clarify information and resolve the concern you may have. The clinic’s phone number is 651-209-8640.
I have read and understand Dakota Child and Family Financial Policy:
Signature: ___________________________________________________________ Date: __________