The office of Dr. Peter Castillo. We want to provide the best care possible to you. A portion of that care involves payment for the services we provide, and this policy explains our policies and procedures. Please return this form to the receptionist once you have reviewed and signed it. A copy will be provided to you upon request.
We Require the following before we can provide you care and treatment:
Once you have seen the doctor and charges for your encounter have been posted, your insurance company will be billed. Following receipt of the explanation of benefits and payment, write-offs and discounts have been taken, or if there is denial of the claim, you will be sent a statement for any balance due. We will gladly work with you on a payment plan for any unusual balances left unpaid.
Special circumstances to this policy are prepayments required for elective surgery.
If no payment is received with your statement, follow up collection letters may be sent. On balances less than $50, we will ‘suspend’ the balance, which will become payable before you may resume care. Unpaid balances over $50 may be referred to a collection agency if there is no response to billings. In this event, you will be responsible for Collection, Court and/or Attorney costs. Failure to pay for services in a timely manner will result in termination of the physician-patient relationship. If you should desire to reestablish your patient-doctor relationship it will be necessary for you to completely pay your collection balance and reimburse the Doctor for any loss.
Termination of care may also result from noncompliance of recommended care including missed or multiple rescheduled appointments.
A service charge of $25 may be made on the following:
Appointments should be cancelled 48 hours in advance. A charge of $50 may be made for no show. We realize that there may be extenuating circumstances in your lives which may cause you to miss an appointment; we do request a phone call to inform us of your inability to keep your appointment. Lack of cancellation denies the doctors the ability to render care to another patient in your place.