Peninsula Gastroenterology Medical Group, Gastroenterologists logo for print
Peninsula Gastroenterology Medical Group, Gastroenterologists
Redwood City: 2900 Whipple Ave | Suite 245 |Redwood City, CA 94062 • Phone: 650-365-3700
Mountain View: 2495 Hospital Drive | Suite 600 | Mountain View, CA 94040 • Phone: 650-964-3636

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Patient Financial Policy Form

Financial Policy

Thank you for choosing Peninsula GI as your health care provider. We are committed to providing you the best possible medical care. Please understand that payment of your bill is important. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. All patients must also complete a Patient Information Form before seeing the physician.

Regarding Insurance

As a courtesy, our office will bill your insurance for the services you will receive. We cannot bill your insurance company unless you give us correct insurance information. It is your responsibility to inform us if your insurance has changed at any time during treatment. Please understand that your bill is ultimately your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 business days, it will then become your responsibility to pay the balance. We accept Cash, Checks and all Major Credit Cards. Please be aware that some, and perhaps all, of the services provided may be non-covered services and may not be considered reasonable and necessary under your medical plan. All co-pays are due at the time of treatment.

We DO NOT accept any Blue Cross Covered California, Blue Cross Pathway EPO, or SutterSelect EPO plans. If you have Blue Cross, it is your responsibility to know if it is through Covered California. If this is realized after your visit, you will be responsible for the entire cost of the visit.

Missed Appointments

Please help us serve you better by keeping your scheduled appointments. To cancel or reschedule an office visit, please do so at least 24 hours in advance. Due to the amount of resources allocated for endoscopic procedures, we require at least 3 full business days' notice for cancellation or rescheduling of appointments. For procedures scheduled with MAC anesthesia, we require 5 full business days' notice. It is our policy to charge a late schedule adjustment fee of $300 for procedures and $75 for office visits. We can waive this fee with a signed doctor's note or if we are able to fill your appointment slot; however, there is no guarantee that we will be able to fill the slot on short notice. The charge for a late cancellation/no-show procedure or appointment will be billed directly to you and not to your insurance.

Ancillary Services

Please be aware that there may be a charge involved for ancillary services such as multiple telephone calls, extended telephone conversations, completing disability forms and/or forms related to your care, and drafting letters on your behalf.

Patient Balances

If payment is not received within 30 days of the statement, a late fee will be applied to your balance as follows:

  • Patient Balances of $0.01-$500.00 will incur a $10.00 late fee each month until payment is received
  • Patient Balances greater than $500.00 will incur a $25.00 late fee each month until payment is received

Thank you for taking the time to review our Financial Policy. Please reach out with any questions or concerns.

I have read and understand the Financial Policy in full.

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Peninsula GI. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment, or an electronic copy, is to be considered as valid as an original.

I understand that I am providing my consent via e-signature by typing my name and clicking submit.

Signature / E-Signature
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