Please be assured that everyone in this practice is dedicated to providing medical care of the highest quality possible to all of our patients, in an atmosphere of caring, trust and mutual respect.
We thank you in advance for taking time to review this policy. Your complete understanding of your financial responsibilitie s is essential; it takes a team that includes patient participation, to succeed with insurance processing and reimbursement. Failure by the insurance company to pay, results in the balance being transferred to the patient for payment.

Our practice policy requires that prior to any services being rendered; all patients must sign the practice financial policy.
We ask that you please present to the office with a form of payment (cash, check or credit card) to meet your obligations to your insurance provider and to your healthcare provider.

Please feel free to discuss any concerns or questions you may have with anyone of our billing staff or our practice manager. We would welcome the opportunity to assist you in your understanding the complexities of health insurance today.

Things to bring with you to your visit:

• Health Insurance Card
• Drivers License or other form of government issued photo
• Method of payment – for your convenience we accept checks, credit cards, debit cards and
  • Please note a thirty dollar ($30.00) processing fee will be applied to any non-sufficient
  • NSF may be referred to the Worthless Check Unit of the Tarrant County Office of the District Attorney, pursuant to Texas Penal Code Sec. 31.06

Assignment of Benefits:

• Jason Harrison, MD, PA, Texas Laparoscopic Bariatrics, PA dba. Highlander Surgical Associates (collectively referred to herein as “HSA”) will bill contracted and non-contracted insurance plans as a courtesy to our patients provided if the patient has provided the required insurance information in a timely manner and has signed a current financial policy and Assignment of Benefits form.

Co-pay, co-insurance and deductibles:

• Payment is due at the time services are This includes in or out of network coverage.
• Co-pay: We are obligated to collect the co-pay at the time of your visit. We are required to do so by your insurance plan. The co-payment amount is determined by your individual insurance policy.
• Deductible: Some insurance plans require that patients pay a predetermined dollar amount prior to services being The amount of money you must pay each year to cover your medical expenses before your health insurance policy starts paying.
• Co-insurance: In addition to the deductible, health insurance plans may have a coinsurance. This is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. Coinsurance rate is usually expressed as a percentage. For example; if the insurance company pays 80 percent of the claim, you are responsible for 20 percent. This portion is due at time of service.
• At no time will co-pay, coinsurance or deductibles be
• Minor Patients: For all services rendered to minor patients, we will look to the accompanying adult or custodial parent or guardian, for payment.
• Ultimately it is your responsibility to call your insurance company to determine what your schedule of benefits allows, if a deductible applies and your potential financial responsibility.

Self “cash” Pay/Fee for Service

• We offer a reasonable discount for our cash pay/fee for service patients who have no health insurance coverage in any form. We are required to provide you with our office policy on this policy, please feel free to ask our front desk if you would like a copy.
• Prior to your visit, you will be provided the visit cost and will be required to pay in full at time of check in on the day of your
• Prior to any surgery, you will be provided an estimate of the surgery cost and will be required to pay in full prior to the surgery date.
• You will be asked to sign a waiver stating that you have no health insurance coverage and will not be filing with any health insurance carrier.

Collections- Referral for Outside collections

• In the event that a balance becomes past due, the account will be considered
• Delinquent accounts may be subject to further collection action, including placement with a collection agency. Accounts that are placed with a collection agency now become the responsibility of the collection agency, Credit Systems International, Inc. In addition, all accounts placed with Credit Systems International, Inc will also be forwarded to three major credit bureaus in which will affect your credit report. The patient is responsible for the balance and any related fees.
• If you account has been forwarded to the collection agency, please contact the agency at: Credit Systems International, Inc. 1227 Country Club Lane, Fort Worth, Texas 76112. Phone: 817/496-6500
• Prior to providing additional services to you, payment in full of total outstanding balances will be

FMLA and other Disability Paperwork

• Special forms are sometimes necessary to provide documentation of medical Completing forms is time consuming and falls outside of the contractual relationship between you and your insurance company.
• We are happy to complete the form(s) for Each form must be accompanied with a filing fee of $25.00 prior to completion. Please allow 15 business days for completion.

Charges for copies of medical records– With Proper signed consent.

• You may request your medical records to be sent to another There is no charge.
• You will be charged for copies of medical records as per Texas Medical Association guidelines, if medical records are released to the patient. This is a pre-pay of twenty five dollars ($25) for the first 20 pages and fifty cents ($0.50) per page thereafter. These charges cover the administrative costs of copying and mailing such records.
• Please allow 15 business days for processing from the time of consent

Phone Appointments

• If you need to discuss a healthcare issue or abnormal test results, you will be asked to schedule an appointment to see your provider; they are longer able to do this by phone.

Professional Courtesy

• Professional courtesy will not be offered in any form to our colleagues in the health related

Refunds:

• Refunds are issued to the appropriate party. Patient refunds will not be processed until all active or past due charges are paid in full. Refunds less than $10.01 will not be issued unless requested.