In order for us to be able to continue to deliver high quality of care, it is necessary to provide a financial policy.PLEASE READ ALL
INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.
Please present your insurance card(s) at each visit. It is your responsibility to provide us with the correct information so
that we may submit to your insurance
We will collect your deductible, co-payment, or for non-covered services along with any balance due after insurance on
your account at the time of your visit. We accept cash, checks, Visa, Mastercard, and Discover.
If we do not participate with your insurance, we will file your claim as a courtesy and ask that you follow up to make sure
payment is made to us in a timely manner. If we do not receive payment from them within 45 days, you will be billed for
any unpaid balance. Balances are expected to be paid in full within 30 days. If payment on your account is not received in
the alloted time, your account may be referred to a collection agency and reported to the credit bureau. We will assess a
1% monthly interest charge on unpaid balances over 60 days old.
COLLECTION AGENCIES- In the event your account becomes delinquent and is turned over to a collection agency
and/or attorney you will be financially responsible for all associated collection fees and legal fees that West Orlando
Internal Medicine, LLC incurs through the process utilized to collect the delinquent balance. Please be advised if your
account is turned over to a collection agency you can be discharged from the practice.
RETURNED CHECKS- Check returned to West Orlando Internal Medicine by the bank will be assessed a returned check
fee, in addition to the original amount of the check. You have ten days (10) to clear up the outstanding check. If you do not
pay the check plus the returned check fee in the specified time, the check will be sent to the State Attorney's office for
MEDICARE PATIENTS- We are participating providers with Medicare and we will submit to Medicare for all your covered
services. If you have supplemental insurance, we will also submit that for you. If payment is not received within 30 days of
being submitted, we will ask you for the balance due. If you do not have a supplemental insurance, your portion (20% of
amount allowed by Medicare) will be collected at each time of service. Each yea you will be expected to pay the allowed
amount of your charges until your Medicare deductible is met
MEDICAID PATIENTS- We are not participating providers with straight Medicaid. We ask that you pay for your services at
the time of each visit. We are participating with Wellcare-Medicaid
HMO-PPO PATIENTS- If we participate with your plan, we will submit your services to the insurance for you. Your
co-payment will be collected at the time of service- no exceptions- If your plan requires you to choose a primary care
physician, it is your responsibility to make sure you contact your insurance carrier and assign Dr. Osama Ansari as your
PCP. If your plan requires you to have an authorization to see a specialist, you will need to obtain that from our office prior
to seeing the specialist. We cannot obtain retroactive referrals. If we do not participate with your plan, we will verify your
out of network benefits, file your services, and we expect payment of your portion of the services at the time they are
SELF-PAY PATIENTS- Patients without insurance coverage will be expected to pay at the time of services, If you are
unable to pay in full, you must contact our credit manager prior to seeing the doctor to make a payment arrangement
NO SHOWS / MISSED APPOINTMENTS/ LAST MINUTE CANCELLATION OR RESCHEDULE- Providers and staff of
West Orlando Internal Medicine, LLC rely on the pre-scheduled appointments and plan their day to day activities. Last
minute reschedules or cancellations and no-shows disrupt the daily activities and also curtall the ability to schedule
another patient in your pre-scheduled slot. If you have to cancel or reschedule your appointment, please provide us with at
least 48 hour notice. Therefore any appointments cancelled without proper notice or any missed appointment will result in
a fee of $25.00.
Remember, whether you have insurance or not, you are ultimately financially responsible for payment of your services. If you have
any questions regarding our financial policy please contact our office manager at 407.338.3939.
I have read and acknowledge the financial policy at West Orlando Internal Medicine.
I hereby authorize my insurance carrier, attorney or any third-party to pay directly to West Orlando Internal Medicine (WOIM) all charges submitted for services incurred by me. I understand I will be responsible for any and charges not paid for by my insurance company. I authorize West Orlando Internal Medicine to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the providers at WOIM which may be due for me from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or in part medical services which I have received. This authorization and assignment shall be valid until I notify West Orlando Internal Medicine in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.