Raffi Tachdjan, MD FINANCIAL POLICY AND CONSENT FOR DISCLOSURE
Insurance and Payment: I understand that I am financially responsible for the payment for any services provided and that the submission of any claim to my insurance plan is a courtesy to me by Raffi Tachdjian MD. I acknowledge that I have confirmed with my insurance plan what coverage and benefits I am entitled to for allergy/immunology specialist, (including in-network vs. out-of-network benefits). I further understand that it is my responsibility to continue to verify such coverage prior to each visit to ensure I am aware of any changes. If I am unable to provide proof of insurance, I understand and agree that I will be considered a “cash” patient and responsible for full payment at the time of service.
Co-payments, Co-insurances, Deductibles, Non-covered Services: I understand that Raffi Tachdjan, MD may or may not have a contract with my insurance plan. In order to determine whether Raffi Tachdjan, MD is a contracted (in-network) provider, I agree it is my responsibility to contact my insurance carrier and ask if Raffi Tachdjan, MD, located at 1301 20th Street, Suite #380, Santa Monica, CA 90404 is a contracted provider. I further understand that Raffi Tachdjan, MD inc. may be required to bill me for any applicable co-payments, co-insurances, Deductibles, or Non-covered Services as directed by my insurance plan. I understand that Raffi Tachdjan, MD has a legal and contractual obligation to bill me these items and may not be permitted to adjust and/or waive any amounts owed by me. Such adjustment or waiver is not permitted by Raffi Tachdjan, MD, and would be in direct violation of Raffi Tachdjan, MD’s contracts with such insurance plans and could jeopardize Raffi Tachdjan, MD’s, and the physician’s participating provider status.
Payments Collected at the Time of Service: Because many PPO insurance plans have annual deductibles and Raffi Tachdjan, MD cannot verify if such deductibles have been met, I understand that Raffi Tachdjan, MD will require payment from me at the time of my visit (see below).I understand that if I have an HMO plan, I must have a properly documented referral/authorization by my insurance before receiving services. Not providing such information at the time of my appointment will result in you being classified as a “cash pay” payment and full payment will be required prior to the provision of services.
Cancellation Policy: Due to being a small office, we maintain a strict cancellation policy. If an appointment is not canceled more than 24 hours in advance, it prevents other patients from waiting to be scheduled for an appointment. Because of this, cancellation within 24 hours (or no-show) of your appointment will be subject to a charge of fifty dollars ($50) to the card number provided below; this charge will not be covered by your insurance company.
I understand that if I hold PPO/EPO insurance, or am SELF-PAY status (Medicare and IPA patients excluded), I am financially responsible for the payment of the listed services below.
X-RAYS and LABS: I understand that any radiology (x-rays), and/or blood work ordered by the physician will not be performed in the Raffi Tachdjan, MD office, and I will be referred to an outside non-affiliated facility which I may go to, or, may choose another provider of my choice. I understand that while these tests may be ordered by the physician, it is my responsibility to understand my insurance coverage for these services.
In-Office Testing (e.g. Skin Testing): If you have a deductible for any testing performed by Raffi Tachdjan, MD in its office, such as skin testing (including patch testing), the office will collect your deductible payment at the time of testing.
Other Non-covered Services: Please understand the services below are considered courtesy services and will not be covered by your insurance, and are therefore subject to a $20.00 fee paid upfront by credit card on file:
- Medical Letters of Necessity (e.g. Travel letters, apartment/housing, special circumstances, etc.)
- School/Summer Camp Forms (*exceptions include same-day school absence form)
- Personal copies of medical records (2+ pages)
- Retroactive Claim Letters for Laboratory or Imaging Services (*as these are separate business entities from Aire Medical of LA)
- Transfer of Antigen Serums to an outside allergist (*subject to a shipping and handling fee starting from $100.00)