Collection of Payment Information at Time of Service

As a requirement for ALL PATIENTS, KC Full Circle Midwifery & Family Wellness requires a credit/debit card to be securely kept on file for all patients, even if your upfront financial responsibility at the time of your visit is determined to be $0. You will be notified in a reasonable timeframe with a statement of your total financial responsibility after insurance processing. If statement balances are not paid within 15 days of your first statement, KC Full Circle Midwifery & Family Wellness will process your card for the balance due. Your signature below authorizes these charges to be paid with your card on file. 

Estimation of Fees

The estimation of fees for your visit is based on typical care needs for the main reason for your visit. However, remaining balances will be determined once insurance processing is completed, and any amount owed will be balance billed. Each person’s individual health needs dictate services rendered. We will make our best determination of the full fee for your visit and provide you with a reasonable estimate prior to your visit. This estimate is subject to change based on your individual healthcare needs determined during your visit. We strive as a clinic to make patients aware of any additional charges or services rendered during the visit.

Self-Pay

We recognize that some patients may elect to self-pay for healthcare regardless of whether they possess insurance coverage or not. For these patients, full payment of the estimated service charges are due at the time of service. In some cases, point of care testing such as a lab draw, urinalysis, or other ancillary service, may be billed following your visit. You will be notified in a reasonable timeframe with a statement of your total financial responsibility after coding and billing is completed within our clinic.

Insurance

To help you get the most from your health insurance plan, we encourage you to become familiar with your insurance plan requirements before seeking care. Failure to bring in a current, up-to-date insurance card requires payment in full at the time of service, for each visit, until we can verify your coverage.

As a courtesy, we will submit claims to your insurance company and will assist you in receiving the full benefit of your health insurance plan. To support you in getting reimbursement in certain cases, we are happy to provide a superbill. It is important to note that billing insurance is not a guarantee of coverage and you may ultimately be responsible for the full balance of your visit, depending on your specific plan. Always be prepared to supply the social security numbers for both the patient, as well as the policyholder. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request in a timely manner. If your insurance changes, please notify us before your next visit so we can make the appropriate changes in our system. 

We participate in most insurance plans, however, if you are not insured by a plan we participate in, you may have a higher out of pocket expense. Many health insurance plans limit the payment for medical services based on their own "usual, customary, and reasonable" (UCR) allowances. If we do not have a contract with your insurance company, the difference between the billed amount and the UCR amount will be billed to you. 

Co-Payments, Coinsurance, and Deductibles

Your insurance company requires us to collect co-payments, co-insurance, and/or unmet deductibles at the time services are rendered. This arrangement is a contract you have with your insurance company. While we will make our best efforts to determine your co-payment or co-insurance obligations at the time of your visit, ultimately, you are responsible for determining your coverage for your specific plan and the type of visit. If we cannot reasonably determine your upfront financial responsibility at the time of your visit, you will be responsible for paying the full fee at the time of service. Please help us in upholding the law by taking care of your responsibility at each visit. Failure to do so may result in a service charge, to help cover our billing costs. Whoever brings a child to the office is responsible for paying their bill, regardless of who is legally responsible for the child’s medical care. 

Appointment No-Shows

If you anticipate that you may be unable to make a scheduled appointment, please notify our office at least 24 hours in advance, so that another patient in need of an appointment might be seen. Failure to notify us may result in a service charge. Please note: If you fail to show up for a scheduled appointment three consecutive times, you may not be permitted to reschedule. 

FMLA Paperwork

KC Full Circle will complete ONE FMLA form per calendar year for a patient free of charge. Each additional FMLA form in a calendar year will be subject to a $25 service charge.

By signing this financial policy at the time of your visit, you agree to the following:

• I am financially responsible to KC Full Circle Midwifery & Family Wellness for all charges incurred, regardless of potential insurance benefits.

• It is my responsibility to verify with my insurance company that the provider(s) treating me are covered under my insurance and in-network, should I prefer to see an in-network provider. If my provider is out-of-network and I still prefer to be seen, I acknowledge this may result in higher financial responsibility. 

• My insurance cards must be presented at the time of the service or I will be considered self-pay until I present my cards, or if insurance changes within treatment, cards must be presented before KC Full Circle Midwifery & Family Wellness will file to new insurance. Co-pays, deductibles, and non-covered services are due at the time of service. 

• I am financially responsible for all charges not covered under my insurance policy arising from any treatment. I understand that if I decline to provide a credit/debit card on file, I will be considered self-pay and responsible for all charges prior to my appointment.

• Your credit card information will be kept on file on a secure platform and only accessed by the last 4 digits of your credit/debit card. 

• I, authorize KC Full Circle Midwifery & Family Wellness to charge my credit/debit card, for the balance due after 15 days of receiving my first statement without payment. I understand my information will be saved on file for future transactions on my account.