Seema Mohan M.D.

PO BOX 5848
P: (480) 595-0431 F: (480) 595-2322

Financial Policy

Thank you for choosing us as your health care provider. We are committed to providing you with quality and affordable healthcare. This billing process notification is developed to assist you with understanding your rights and responsibility when receiving services with Carefree Internal Medicine.

Insurance: Carefree Internal Medicine participates in most insurance plans, including Medicare. If you are not insured by a participating plan, payment in full is expected at the time of each visit. If you are covered by a participating plan, but are either missing an updated insurance card or you cannot provide policy and group number, you will be responsible. You will be required to pay in full at time of visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Proof of Insurance: All patients must confirm and/or complete a patient information form before being seen. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Non-Covered Services: Please be aware that some and perhaps all of the services you receive may be non-covered or not considered reasonable or necessary by your insurers. You will be billed for these services.

Change in Insurance Plans: You are expected to notify our office promptly if your insurance coverage changes. We will ask you to update your record at each visit to our office. It is also your responsibility to notify the office immediately of these changes. Balances left over 90 days will become the responsibility of the patient. Insurance carriers give us 90-day period to submit claims to them for payment. After that time, it will be denied as past timely filing. If we are unable to process your claim due to incorrect information given, we will bill you directly for our services.

Claims Submission: We will submit your claims and assist you in any way reasonable to help get your claim paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. If payment is denied due to a lack of response from you, the balance will immediately become due and payable by you. Your insurance benefit is a contract between you and your insurance company. We are not party to the contract. We have an external billing company and, as business associates, they are bound by HIPAA regulations and compliance.

Payment is Required at the Time of Service: Patients who are not covered by health insurance, on a plan that we do not participate with, or if we are not able to verify your coverage, you must pay in full at the time if service. Payment is required at time of service, unless a payment plan has been arranged with our office. Patients who have plans that we do participate with are asked to pay their co-payment, co-insurance, deductibles, or non-covered services at the time of their visit.

Self-Pay: We want to provide uninsured patients with quality and affordable healthcare. Payments must be made in full at the time of service before leaving the office. No discounts will be offered.

Nonpayment: Should your account become 90 days delinquent, you will receive a letter stating that you have 10 days to pay your account in full. Patient payments will not be accepted unless otherwise negotiated with a member of our business office. Please be aware that if a balance remains unpaid, we will refer your account to a collection agency. The patient or guarantor will be responsible for all costs of collection including attorney fees, collection fees and contingent fees to collection agencies of not less than 35 percent. The contingency fees will be added and collected by the collection agency immediately upon our referral of your account to the collection agency of our choice.

Third Party Billing: we do not do any third party billing, follow-up or related activity. If a third party may be involved, it will be the patient’s responsibility to seek reimbursement. Patients involved with a third party payer will be expected to provide health insurance or if uninsured, will fall under the self-pay guidelines.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. For returned checks, you will be charged a $40 return fee.
Thank you for understanding our financial policy. Please let us know if you have any questions.

I have read and understand the financial policy and agree to abide by its guidelines.

Charges for missed appointments
15 minute appointment the charge is $40.00
30 minute appointment the charge is $80.00

Health form fees and Prescription refill notice

Due to administrative time involved in filling out health care forms there is a charge for all forms including but not limited to……

  • Insurance forms
  • Physical forms
  • Medical leave act forms
  • Any form pertaining to health information
Fee: $15 Basic Form
Fee: $25 Rushed (24-48 hours)
Fee: $20 Family/medical leave form
Fee: $35 Medical records-patient pick up
Fee: $45 Lawyer records transfer (or other requesting agencies)

Fees do not apply to each form; all fees are due at the time of request.

Completed forms will not be released until payment has been recieved.

Prescription Refills

We require at least 48 hours to process and complete all medication refill requests.

Please feel free to leave a message for your provider regarding any concerns you may have – (480)595-0431