Thank you for choosing Daniels and Peck Family Medicine, PA as your primary care provider. We are committed to providing you with quality and affordable health care. The following information has been provided to help answer some of the most frequently asked questions. Please read it, ask us any additional questions you may have, and sign in the space provided. A copy will be provided to you upon request.
1. Insurance. We see and provide care to patients with any insurance plan or who have no insurance. However we only participate with BCBS, Cigna and Medcost insurance plans at this time. We provide care to Medicare patients as a non-participating provider and do not accept assignment. If you are not insured by a plan that we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service.
3. Non-covered services. Please be aware that some-and perhaps all-of the services you receive may not be covered or may not be considered “reasonable or necessary” by Medicare or other insurers. You must pay for these services in full at the time of your visit. We will try to notify you in advance if a service may not be covered.
4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If your fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
5. Claims submission. If you have Cigna, Medcost, Medicare, or BCBS of NC we will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. If you have insurance with any other plan not listed above, we will provide you with a form with the necessary information that will help you file your claim on your own.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payment will not be accepted unless otherwise arranged. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, your will be notified by regular and certified mail that you have 30 days to find alternative care. During that 30-day period, our physicians will only be able to treat you on an emergency basis.
8. Missed appointments. Our policy is to charge for missed appointments that are canceled or rescheduled without a 24 hour notice. These charges will be your responsibility and billed directly to you. Please help us to serve you and others better by keeping your regularly scheduled appointment.
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.
I have read and understand the payment policy and agree to abide by its guidelines.
Signature of patient or responsible party Date
Click here to download this policy so you can print it, sign it and bring it to your initial appointment.
Medicare patients - please click here to read this policy, too.