We strive to make every experience with us a positive one. However, due to the increasing complexity of insurance policies and managed care regulations, we recognize that patients may not always fully understand the relationship between their insurance provider, their physician, and themselves.

To clarify this relationship and outline financial responsibilities, we have developed the following guidelines. If you have any questions, please speak with our insurance office staff. You will be asked to sign at the end of this form to acknowledge your understanding and agreement.

Insurance Card Requirement

You must present your insurance card before or at the time of your visit. If we do not receive your insurance information before your appointment, the visit will be considered fee-for-service, and full payment will be required at that time unless other arrangements are made.

Co-Payments, Deductibles, and Co-Insurance

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Co-Payment: A fixed amount you owe for each office visit, as determined by your insurance plan.

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Deductible & Co-Insurance: Some insurance plans require patients to meet a deductible and pay co-insurance before coverage applies. If your deductible has not been met, you will be required to pay your co-payment, deductible, and co-insurance amount at the time of service.

Laboratory & Pathology Fees

At times, lab tests or pathology examinations are necessary for diagnosis and treatment. While we may collect specimens in our office, the actual testing is often performed by an outside laboratory or pathologist.

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You will receive a separate bill from the lab, pathologist, or another provider conducting the tests.

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If your insurance requires a specific lab, please inform us before testing.

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You are responsible for any charges incurred from laboratory or pathology services. If you receive a bill from a lab, please contact them directly regarding billing concerns.

Accepted Forms of Payment

For your convenience, we accept the following payment methods:

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Cash, Personal Checks, MasterCard, Visa, Discover

Returned Checks

A $35.00 non-sufficient funds (NSF) fee will be applied to your account for any returned checks.

Fee Estimates

We are happy to provide an estimate of service fees when possible. However, the exact cost of a procedure can only be determined on the day of service after the physician has assigned the appropriate billing code. Estimates do not include charges from outside labs or pathology services.

Collections & Outstanding Balances

We are committed to working with you to establish a payment plan if your account becomes past due. However, if all reasonable efforts to resolve your balance are unsuccessful, your account may be referred to an outside collection agency.

Acknowledgment & Agreement

By signing below, I acknowledge that I have read and understand this Financial Policy. I agree to comply with these terms and accept full financial responsibility for my medical care.

I authorize Siouxland Obstetrics & Gynecology, PC to file insurance claims on my behalf and assign all medical reimbursement benefits directly to the practice. Additionally, I authorize the release of necessary medical information to my insurance carrier for claims processing.

I understand that in the event of a denied claim, I am responsible for any remaining balance