Financial Policy Form

Financial Policy

  • Jose A. Gaudier, MD, PA. Financial Policies
  • We are committed to providing the highest level of medical care to our patients. To ensure that our patients fully understand our billing process, we ask that you read and sign this financial policy statement.
  • Insurance Policy

    It is the policy of Jose A. Gaudier, MD, PA. to file insurance as a courtesy to our patients; however, deductibles, co-payments and co-insurance are expected to be paid at the time of service. We do not accept responsibility for communications of collections from your insurance company. If we have not received payment from your insurance company within 60 days of the date of service, the responsibility for that payment will transfer to the patient and payment in full will be expected at that time. If under certain circumstances, you are required to file your own insurance, you will be provided with the required information.
  • Self-Pay Accounts

    If you do not have insurance, payment in full for all services is expected at the time the services are rendered.
  • All Accounts

    Patients are informed that we may, at our discretion, refer an unpaid account to a collection agency or credit reporting agency. Any cost relating to the collection agency for lack of payment will be added to your balance. You will no longer be seen in the office until your account is paid in full.
  • Referrals

    All of our HMO patients requiring our services will need to have a referral/authorization depending on their health plan. This comes from the primary care physician. If our office does not have this at the time of your appointment, your visit will need to be rescheduled.
  • Missed Appointments

    It is the policy of Jose A. Gaudier, MD, PA to confirm appointments at least 24 hours prior to the date of the appointment. When you need to cancel or rebook a scheduled visit, we expect you to contact our office no later than 24 hours before the scheduled visit. This allows us a reasonable amount of time to determine the most appropriate way to reschedule your care as well as giving us the opportunity to rebook the now vacant appointment slot with another patient.
  • Consequences of “No-Show” Appointments (please accept)

  • Returned Checks

    There will be a $35 returned check fee added on all returned checks.
  • I have read and understood the above policies of Jose A. Gaudier, MD, PA.
  • An electronic or photocopy of this acknowledgment shall be valid as the original.