Patient Financial Policy

Welcome to Oklahoma Oncology. The purpose of this information sheet is to help acquaint you with the services and the financial policies of Oklahoma Oncology.

ASSIGNMENT OF INSURANCE BENEFITS
I agree that physician benefits otherwise payable to the insured are to be made payable to the physician(s) responsible for my care. Any payment received for this period may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits.

PRECERTIFICATION POLICY
I understand that Oklahoma Oncology will assist with insurance pre-certification requirements, but will not assume responsibility for pre-certification or any impact which it may have on insurance payment.

FINANCIAL RESPONSIBILITY
As consideration for the services provided me, payment is guaranteed for any amount due for such services provided by Oklahoma Oncology. Charges for services and goods shall be at Oklahoma Oncology billed charges rates unless otherwise agreed to in writing by Oklahoma Oncology.
  • As a service to all of our patients, we will file medical insurance claim forms with your insurance carrier or Medicare. To help us better serve you, please let us know when you change insurance plans or have a change in benefits.
  • Medicare Patients: The physicians of Oklahoma Oncology are proud to be "Participating Providers" of medical services under the Medicare program. As Participating Providers, we agree to accept an amount of payment equal to the Medicare "allowable" for covered services. Medicare pays 80% of the allowable, and the patient, or the patient’s secondary insurance, is responsible for paying the remaining 20% of the allowable and any deductibles.
  • Please be prepared to make a co-payment at the time of your visit if your insurance plan requires an office visit co-payment.
  • Generally, we will not send you a statement until we have received payment from your insurance company. When you do receive a statement, it will indicate the amount of your charges, the insurance payments and the amount that you owe for co-insurance, deductible, etc.
  • In some cases, we may have to send you a statement and ask you to make regular monthly payments - even before your insurance company has paid us - if your insurance company has delayed payment or has not paid appropriately.
  • Our business office staff can help you arrange a fair monthly payment schedule for balances not paid by your insurance company. We accept VISA, MASTERCARD, and DISCOVER.
  • There will be a $20.00 service charge for all returned checks.

"I hereby assign all medical and/or surgical benefits to Oklahoma Oncology. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize Oklahoma Oncology to release all information necessary to secure payment."

 
  (Patient or Responsible Party)