The Ear Institute of Chicago, LLC Financial Policy

SUMMARY of our financial policy:

• Payment is expected at the time of service, unless other arrangements have been made in advance. For patients who carry participating insurance plans, expected payment includes all applicable deductibles, co-payment, and co-insurance payments.

• For patients who do not have insurance, payment in full is due at the time of service.

• We accept cash, personal check (in-state), and Visa or MasterCard payment.

• We charge a service fee for returned checks ($30).

• We require patients to store a credit card on file, and we reserve the right to charge the credit card on file for account balances over 30 days past insurance collections. [SEE BELOW]

DETAILS of our financial policy:

Insurance:  We expect you to pay your deductible, co-insurance, and co-payments at the time of service. You are responsible to know what is covered and what is not covered by your insurance plan. If your insurance chooses not to pay the Ear Institute of Chicago, or if your insurance company chooses to delay payment, you are responsible for payment. If your insurance company has not paid us within 60 days of the date of service, we expect you to pay the balance in full.

If you need assistance or have questions regarding your insurance claim, please contact our billing company, Trellis, at 847-885-1675 between 9:00am and 5:00 pm Monday through Friday.

Confirmation of insurance coverage:  If we do not have confirmation of insurance coverage by either a current insurance card, letter of eligibility from an insurance company, or any other form of confirmation of coverage, the patient or responsible party will be responsible for all charges incurred. 

Hearing and Diagnostic tests:  Many insurance companies do not cover hearing tests (audiograms etc.) even though your physician may find it necessary.  If this occurs and you agree to proceed with these services or any other services not covered by your insurance, the patient or responsible party is responsible for payment.

Credit Card Storage: We require that all patients store a credit card on file in order to guarantee payment for services. Credit card information will be stored in a highly encrypted manner. No charges will be applied to your credit card except in the following instances: 1. We reserve the right to charge your credit card on file for the balance due if your account becomes more than 30 days past insurance collections, and you have made no response to our statements requesting payment. 2. For your convenience, you may also choose to have your credit card automatically charged for balances owed after insurance has paid.

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Forms Completed: We charge $30 for the completion of forms (for example, disability, life insurance, etc.). We require 7-10 working days to complete any form.

Copies of Medical Records: We require a signed medical records release before we process any request for medical records.  We charge $.92 per page for the first 25 pages, $.61 for pages 26 to 50, and $.31 for pages over 50.  We require 10 business days after we receive the signed request to process a request for medical records.

Billing Statements: We will send you one statement for service at no charge; however, a $5 statement generation fee will apply for each additional statement.

Delinquent accounts: If your delinquent account is referred to a collection agency, you will not be seen by a physician until all balances are paid in full unless a physician of the Ear Institute of Chicago, LLC determines that your condition is either medically emergent or urgent.

Collections: If your account becomes delinquent and is referred to a collection agency, you will be responsible for paying the unpaid balance, collection fees and/or any attorney fees (which may be 35% over and above your outstanding balance).  Information allowable by law that may be helpful or necessary in the collection process will be forwarded to the collection agency.

Canceled, Late, and Missed Appointments: Patients will be charged $50.00 for missed appointments unless the office is notified at least 24 hours prior to the scheduled appointment. 

Acknowledgement

I agree that I have read and understand the Ear Institute of Chicago, LLC’s Financial Policy and consent to the terms thereof.

I agree to assign insurance benefits to the Ear Institute of Chicago, LLC whenever requested and whenever necessary to facilitate payment of a claim.

Authorized Name (Print): ______________________________________________________________________________

Authorized Signature: _________________________________________________________________________________

Date: _________________________________________________