Financial Policies

1.   Co-payments and/or co-insurance are due at the time of service.  Due to legal considerations this policy must be applied uniformly.

2.   Insurance requires pre-authorization. Payment in full is expected without proof of authorization.  The appropriate payment is required at each visit, if the patient is a minor; payment is still required regardless of the relationship of the adult to the minor. In the case of children of divorced parents, payment is due at the time of service regardless of the terms of the divorce decree.

3.   C.P.G. will bill insurance for the patient.

4.  Physician fees for inpatient services are billed separately from the hospital charges.
 

5.  Administrative charges:
 

Please note: If the information you provide is not correct and kept current the balance becomes your responsibility at CPG’s fee schedule.  We realize that emergencies do arise and may affect timely payment of your account.  If such extreme cases do occur, please contact us promptly for assistance in the management of your account.

If it becomes necessary to collect any sum due through an attorney or collection agency, then the guarantor agrees to pay all reasonable costs of collection, including attorney’s fees, whether the suit is filed or not.

______________________________
Patient signature


______________________________
Guarantor signature  


_____________
Date