Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD believes that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy.

1. PAYMENT is expected at the time of your visit. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit. We do ask for a copy of an ID card of license due to the many cases of identity theft in the news lately. (Please do not be offended!)

2. INSURANCE We are participating providers with several insurance plans. We will file all of these insurance claims. A list of these insurance plans is available upon request. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you will be billed. If we later receive payment for your insurer, we will refund any overpayment to you.

If our doctors are not listed in your plan’s network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim in for you on an unassigned basis. This means the insurer may send the payment directly to you and therefore, our charges for you are due at the time of service. Due to the many different insurance products out there, our staff can not guarantee your eligibility and coverage. Be sure to check with your insurer’s member benefits department about services and physicians before your appointment. Many web sites have erroneous information and are not a guarantee of coverage. You are responsible for obtaining a properly dated referral if required by your insurer and responsible for payment if your claim rejects for the lack of one.

Not all insurance plans cover all services. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement form from our office. All procedures billed in this office are considered covered unless limited by your specific insurance policy.

3. RETURNED CHECKS will incur a $35.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $35 service charge to pay the balance prior to receiving services from our staff or the physician. Stop payments constitute a breach of payment and are subject to the $35 service fee and collections action. All bad checks written to this office are subject to collections and will be prosecuted in Santa Clara County.

4. ACCOUNTING PRINCIPALS Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding dates of service.

5. BILLING OFFICE: If you have questions in regards to any of your billing statements, our accounts receivable staff is available to assist you. CALL 888-461-7001 or 209-661-4413.

6. RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD for charges not covered by the assignment of insurance benefits.

7. ASSIGNMENT OF INSURANCE BENEFITS: I hereby assign, transfer, and set over directly to Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD sufficient monies and/or benefits for basic and major medical to which I may be entitled for professional and medical care, to cover the costs of the care and treatment rendered to myself or my dependent in said clinic. I authorize Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD. I authorize Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD to release all medical information (including, but not limited to, information on psychiatric conditions, sickle cell anemia, alcohol and drug abuse, and HIV or communicable diseases) requested by my health insurance carrier, Medicare, other physicians or providers, and any other third-party payers.

8. SELF PAY PATIENTS OR PROMPT PAY PATIENTS WHO ARE INSURED: A 20% prompt pay discount is applied to all full pay payments received at the time of service whether or not you carry insurance. This means anyone willing to/or needing to pay in full at the time of service will receive a 20% discount off of the evaluation and management service codes only. Charges for supplies, tests, immunizations, medications, or procedures are not discounted. Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD do not make payment arrangements or extend credit. All services are expected to be paid in full at the time of service. By signing below I state that I am not eligible for Medicaid and will never ask this office to bill them.

9. RELEASE OF INFORMATION: I hereby authorize and direct Gopi Ayer MD, Mandeep Ayer MD, Jane Chien MD to release to governmental agencies, insurance carriers, or others who are financially liable for such professional and medical care, all the information needed to substantiate claim and payment.

10. COLLECTION FEES: I understand that in the event my account is placed in collection status, any additional fees incurred due to this, will be added to my outstanding balance. This includes but is not limited to late fees, collection agency fees, court costs, interest and fines. I understand that these additional fees will be my personal responsibility to pay in full.

11. NON FACE TO FACE SERVICES: Patient authorizes physician to bill insurance, such as Medicare, for non-face to face services, such as consultations with other physicians and electronic/telephone communication with patients, as allowed by Medicare and other insurances.