213 Greenhill Ave. Wilmington, DE 19805
(302) 429-5870
Please enable JavaScript in your browser to complete this form.

Family Medicine at Greenhill Office Financial Policy

Thank you for choosing Family Medicine at Greenhill (FMAG hereafter) as your healthcare provider. FMAG is committed to your care. Please understand that payment of your bill is considered a part of your care. We require you to read and sign this statement prior to seeing your health care provider.

How may I pay? Payments can be made by cash, money order, check, debit or credit card. A returned check fee in the amount of $35.00 may be assessed to your account for every check returned for insufficient funds, stopped payment or a closed account.

What is my responsibility for my insurance plan's requirements? Our staff interacts with many insurance companies, each with different rules and regulations. Although we will do our best to assist with your insurance company's requirements, it is the patient's responsibility to ensure that all required permissions are obtained including referral, pre-certification, pre-authorization and using in-network facilities. You will be responsible for the entire bill if payment is denied by the insurance company for failure to obtain the requirements.

Insurance and Personal Information: It is your responsibility to ensure we have the most current information possible. You must bring your insurance card with you to each visit and notify us of any changes in address, phone number or marital status.

Co-payments: FMAG is contracted with most insurance providers and is contractually required to collect ALL co-pays prior to service. Please be prepared to pay the co-pay at each visit.

Minors and Dependents: Parents are financially responsible for care rendered to their minor child(ren). As many insurance companies cover adult child(ren) who are full-time students, it will be the parents' responsibility for any balance on the account. I further understand that both biological parents have access to full disclosure (even if not the custodial parent) and both can authorize representatives unless parental rights have been terminated by court order. I understand if there are Custody Orders in place, I must present current copies for my child’s file. I authorize the people listed to bring my child to any appointments in my absence and FMAG may call and leave a message regarding my child’s clinical care, including lab and x-ray results in my absence. I understand this authorization for release of information will remain in effect until parent or guardian changes their disclosure with FMAG in writing. At that time this authorization will expire. I authorize FMAG, only upon my request, to fax any forms or immunization records to my child’s school. I authorize FMAG to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such care to third party payers, my health insurance, my attorney, and/or other health practitioners. I authorize my insurance plan to make direct payment of medical benefits, to include major medical benefits, to FMAG.

Motor Vehicle Accidents: We are pleased to see patients for Motor Vehicle Accidents however, to meet legal requirements, we must have full insurance details, claim number and claim address so that we can process authorization before the time of your visit. If these are not available, then your visit may be regarded as a self-pay appointment. We cannot bill private medical insurance for these claims since they are generally not covered. We do not accept Workers' Compensation cases.

Form Completion We will complete forms submitted to our practice during a scheduled office visit ONLY.

Missed Appointments: We require at least 24 hours' notice for cancellation of appointments. New patient appointments that are not canceled with required 24-hour notice will be counted as a No Show. New Patients who No Show for the first appointment will not be rescheduled. For established patients we have a three-strike policy and patients who repeatedly miss appointments may be asked to find another provider.

Chronic Care Management: This service allows FMAG to provide care coordination in between office visits. If I qualify, I agree to participate and understand that I will be responsible to pay my copay and/or deductible based on my insurance.

Medicare: Our physicians have agreed to accept assignment on all Medicare claims. Accepting assignment means that we must accept Medicare's approved amounts. However, you should know that Medicare only pays a portion (generally 80%) of the approved amount above your deductible. In addition to your deductible, you are responsible for the other portion (generally 20%) of the approved amount unless you have a supplemental plan that covers these fees. You will be billed for any allowable balance not covered by Medicare and/or your supplemental insurance plan.

By signing below, I have read, understand and agree with and will abide by the terms of FMAG’s policies listed above.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.