SOUTH ATLANTA DIGESTIVE DISEASES ASSOCIATES
FINANCIAL DISCLOSURE STATEMENT
Thank you for choosing SADDA. Please read and sign this Financial Disclosure Statement prior to your appointment.
Patients who do not pay in full at the time of service must complete the required information and insurance forms before service will be rendered.
You can expect to receive the following bills as a result of your visit:
- Physician Fee: Fee to be paid to the physician for performing the service. This bill will be from SADDA (South Atlanta Digestive Diseases Associates).
- Lab Fee: If a lab test is ordered, a second bill will come from a lab or a radiologist.
Some insurance companies require precertification for this service. We will make every effort to verify your benefits and obtain any necessary precertification prior to your appointment. This is not a guarantee of payment. Your insurance company will send you an Explanation of Benefits that will explain how your bill was paid by them and any amount for which you may be responsible. It is your responsibility to understand your insurance benefits. Some insurance plans require you to pay different out-of-pocket amounts based on the location where service is performed. Deductibles, co-insurance and co-payments may also apply according to your insurance plan. By law, you are responsible for these amounts, as well as any non-covered services outlined in your health plan. We will submit primary, secondary and tertiary claims on your behalf as long as the information needed to process the claim is obtained and verified before your visit. If this information is obtained after your visit, the patient or guarantor is responsible for the balance. We accept cash, checks and major credit cards. SADDA will collect co-payments at the time of service.
Additional payment may be required based on your insurance plan. If you have a balance due, your payment will be applied to the oldest balance first. In the event your account has a credit or overpayment on your account, we reserve the right to transfer credits to any outstanding balances prior to issuing a refund.
Additional questions regarding billing or payment arrangements should be directed to our billing staff. If you are unable to keep your appointment, please contact our office to cancel or reschedule your appointment at least 24 hours in advance. A missed appointment will result in a $50 fee. A $30 fee will be incurred for returned checks.
PATIENT’S REASSIGNMENT AND RELEASE STATEMENT
By signing below, I understand the billing practices of SADDA and its affiliates and that I may receive multiple bills related to my service as explained above. I authorize payment of medical benefits to SADDA and its affiliates and authorize them to release any medical information necessary to process claims. I give SADDA permission to apply payments received to balances due at SADDA, and I understand that payments will be applied to the oldest balance first. I understand that I am financially responsible for any co-payments, deductibles, co-insurance and non-covered services.
*Patient / Authorized Representative Signature (If patient is a minor (under the age of 18), form must be signed by a parent or legal guardian.)
