OUTPATIENT SURGICAL CENTER OF PONCA CITY
400 FAIRVIEW, STE. 50 – PONCA CITY, OK  74601
PHONE 580-762-0695  FAX 580-765-9406

PAYMENT POLICY

click here for printable version

Our primary goal at the Outpatient Surgical Center of Ponca City is to provide a high standard of quality care to our patients and their families at substantial savings.  The following is a statement of our Financial Policy, which we require you to read and sign prior to treatment.

Estimated Fees for Your Procedure
You will be provided a written estimate of the proposed surgical procedure charges.  If there are multiple surgical procedures performed, the surgical charges will be presented to you at full charge.  For multiple procedures, there will be adjustments made by your insurance plan or managed care contract once a claim has been  presented for services rendered.  We provide you with an estimated procedure charge to assist you in the budgeting of your surgical expense.  Fees for the services of your surgeon, anesthesiologist and/or pathologist are NOT included in the estimated charges presented to you by the center.  You may wish to contact Dr. Coldiron’s office 765-0673 to find out whether she is in network with your insurance.

Insurance Coverage
IT IS YOUR RESPONSIBILITY TO CONTACT YOUR INSURANCE COMPANY TO VERIFY COVERAGE AND PRECERTIFICATION PRIOR TO YOUR SURGICAL PROCEDURE
Your primary and secondary insurance will be filed by the Center at no charge; however, your insurance policy is a contract between you and your insurance company – we are not a party to that contract.  You are responsible for our entire bill, whether your insurance company pays or not.  If your insurance company does not pay its portion within 90 days, the balance will be transferred to you.  Please be aware that some services and/or supplies provided may be non-covered services with your insurance.  Charges such as these are the patient’s responsibility to pay.  Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area.  You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Workers Compensation. Liability Insurance Oklahoma Medicaid and Medicare claims will be filed by the Center, with no amount due at the time of surgery.  Please be aware that if our claim is denied for any reason, the balance will be your responsibility. This does not apply to Medicare claims.

Regarding Personal Injury/Accident Claims – the patient or their parents/guardians are the responsible party(ies).  We suggest that all claims for these services be forwarded to your private medical insurance.  We will file a lien with your liability insurance and your attorney in accordance with our policy; however, we reserve the right to demand payment at any time, regardless of lien status.

No Insurance Coverage – any patient without insurance coverage can either pay their balance in full, or pay a required 25% deposit of your estimated surgical fee by cash, credit card, or money order, with a payment agreement established with the Business Office before their procedure takes place.

PAYMENT OF A PORTION OR ALL ESTIMATED PATIENT RESPONSIBILITY IS REQUIRED PRIOR TO THE SURGICAL PROCEDURE

We accept Visa, Mastercard, Check, Money Order, and Cash

DELIQUENT ACCOUNTS
All accounts that are delinquent over 30 days will enter the Center’s collection process.  Collection actions include Collection Agencies, Small Claims and Civil Court, and garnishments.  If we have to refer your account to a collection agency or small claims court, you agree to pay all of the collection cost and/or court cost which are incurred.  If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer’s fees which we incur plus all court costs.

Guarantor Signature: ______________________________________SSN: _____________________

Date: ____________­­_­­­­__