Financial Policy

Dear Patient:

You have been referred to Abhay Gupta, M.D., F.A.C.S. and Gupta Plastic Surgery for evaluation and/or surgical care to you based on your medical needs. We are here to assist you through this process. You may require additional visits to our office. To schedule these visits, please call 858­621­6000. Our continuing goal at Gupta Plastic Surgery is to provide you with the quality healthcare you deserve. We have developed the following information to clarify our billing policies for you.

VERIFICATION OF COVERAGE is required before your insurance is billed. It is your responsibility to provide us with your current insurance information. If we do not have a current copy of your insurance card, you will be responsible for payment. I t is very important that you understand your insurance benefits. We recommended that you contact your insurance company before any services are rendered so that you have a clear understanding of what services are covered. If there is ever a question between the information we received from your insurance company and what you know your coverage to be, it is your responsibility to provide us with written documentation from the insurance company of the correct information. If your insurance does not cover your treatment, you will be responsible for payment as described herein.

PAYMENT FOR SERVICES: As a courtesy to you, we will bill your insurance for the services provided to you during your stay. Should your insurance fail to pay for these services, you will be financially responsible. For questions about your bill, please call 858‐621‐6000 and ask for the billing department. If you do not have insurance, or we are not contracted with your insurance, you are expected to pay for your services at the point of check in. This is done so that you are not faced with an unexpected bill after your visit.

COPAYMENTS, DEDUCTIBLES AND NON­COVERED SERVICES are calculated and are due at the time of service.

INSURANCE BILLING: As a service to you, we will bill covered services to those primary and secondary insurance plans with which we are contracted. If we are not contracted with your plan, or the services you are receiving are not covered, you are required to pay for your services at the time services are rendered. Should you request, we will provide you with the necessary paperwork to submit to your insurance company for reimbursement.

APPOINTMENT CANCELLATIONS/CHANGES: Minimum 24‐hour notice is required for all appointment changes and cancellations. This will allow other patients the opportunity to utilize the appointment time. You will be charged a $50 fee for all appointments where 24‐notice was not provided.

LATE PAYMENTS: A $25.00 fee will be assessed to fees due that are not paid at time of the visit. This includes all co‐payments.

RETURNED CHECKS: A $50.00 fee will be added to each returned check.

FORM COMPLETION: Should you have forms to be completed by your provider, please check with our receptionist to verify if a fee is applicable. Fees must be paid prior to form completion.

CHANGE TO YOUR INFORMATION: It is very important that you notify us as soon as possible of any changes to your address, telephone numbers, employment, insurance and/or name changes so that we may keep your records as up to date as possible.