South Central Kansas Clinic Financial Policy

Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.


1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we contract with, payment in full is expected at each visit. If you are insured by a plan we contract with, but don’t have a current insurance card, payment in full for each visit is required until we can verify your coverage. Every health insurance policy is different.  It is your responsibility to become familiar with your own policy. Please contact your insurance company with any questions you may have regarding your coverage.


2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit and keeping your account current.


3.  No insurance.   If you do not have insurance, payment in full is expected before the visit.  We do offer discounted fees for patients without medical insurance.


4. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payment for all such services.


5. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license or identification card and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim.


6. Claims submission. We will submit your claims to your health insurance company and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request(s). Please be aware that the balance of your claim(s) is your responsibility regardless if your insurance company pays or denies your claim(s). Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.


7. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.


8. Nonpayment. Patients with delinquent balance are required to make payment in full for future services. Partial payments will not be accepted.  Some accounts may be eligible for resolution with a payment plan.  If a payment plan is negotiated, timely payments per the plan are required, no exceptions. New reminders will not be sent on such accounts. If a payment is missed, the account will automatically be referred to collections.  Patients with accounts that have been referred to collections may be discharged from our practice along with any family members that they are guarantor of.  A patient who is discharged will be notified by certified mail.


8. Missed Appointments. Broken appointments, “no shows”, represent a cost to us and to other patients who could have been seen in the time set aside for you.  A 24 hour notice is required for any cancellation.  We reserve the right to charge $20.00 for late cancellations or no-show appointments. The no show fee cannot be billed to your insurance company; you are directly responsible for payment on or before your next appointment.  Three (3) no show appointments are considered chronic and patient will be discharged from the practice for failed professional relationship. Please help us to serve you better by keeping your regularly scheduled appointment.


9.  Medication Refills.  Monitor your medication usage and plan your monthly follow-up visits if you need refills.  No refills will be given if appointments are missed.  Refill requests require 48-hour notice.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.


I have read and understand the payment policy and agree to abide by its guidelines:



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Signature of patient or responsible party                                Date