• I understand that as an insured patient, I am responsible for any administrative fees and all medical charges regardless of decisions made by my insurance plan. Due to the nature of submitting claims to insurance plans and delays in payment, any finance charge and invoicing fee will be retroactive to the date of service.
• Insured patients are responsible for providing accurate insurance information at the time of service, including proof of insurance coverage. Any insured patient who fails to submit an insurance card will be treated as a cash pay patient and is subject to cash pay rates.
• Invoicing fee in the amount of $10.00 per invoice to cover postage and time spent generating a paper invoice. Electronic invoicing through our appointment program is free of charge. You must provide a valid email address to qualify for electronic invoices.
• The annual finance charge of 18% will be applied to the unpaid account balance (1.5% per month).
• Once the unpaid account balance reaches 30 days maturation from the date of service, the account will be turned over to small claims court or a collection agency, unless special arrangements have been made with Doctor Kara PC for installment payments on overdue balances.
• In the event legal action is taken to collect on the account, an additional amount of 50% of the principal balance will be added to offset the costs of attorney’s fees, court costs, or collection agency actions. This additional amount is in recognition of the costs associated with collection action processing.
• In the event Doctor Kara, P.C. is unable to obtain a valid payment I agree to pay an additional administrative fee of $15.00 per occurrence to offset the time and effort spent in notifying me of an invalid payment.
• All communication and inquiries to Doctor Kara, P.C. about my account must be submitted in writing by the account holder (or executor of the estate in cases of a deceased account holder). Doctor Kara, P.C. will respond in writing within 7 calendar days, except during periods of extended absence. Office closure dates will be posted on the clinic website and the office entrance. I agree to notify the office in writing of any changes in my contact information (name, address, phone number, work number, etc). I hold Doctor Kara, P.C. blameless for lost communication in the event I fail to maintain accurate contact information with the office.
• The information given in the registration form is valid and true to the best of my knowledge. I understand I am financially responsible for all office charges payable to Doctor Kara, PC. I also authorize Doctor Kara PC to release limited medical information to expedite the process of requesting lab or diagnostic tests and necessary medical referrals to other medical professionals during the course of my treatment.

Patients further acknowledge:

• Patient is the authorized card holder of the credit card listed on the Patient Registration Form page 1.
• The patient designates the credit card listed on thePatient Registration Form page 1 as the “credit card of record” for the account.
• In the event the credit card of record is reported as lost or stolen, the patient will provide the clinic with new and valid credit card information as the credit card of record to maintain an account in good standing.
• The patient authorizes the clinic to make charges against the credit card of record in accordance to the terms and conditions listed in the billing policy, appointment policy, or any other special contracts the patient holds with the clinic (i.e. VIP membership).
• The patient is responsible for maintaining accurate and valid payment information with the clinic to facilitate valid payment for medical services requested and/or received.
• In the event we are unable to obtain a valid payment, using the credit card of record, the patient agrees to pay an additional administrative fee of $15.00 per occurrence.
• Credit refunds will only be made to the credit card of record within 3 business days. Cash refunds cannot be issued against accounts paid with credit cards.
• The patient acknowledges that if he or she misrepresents personal and financial facts to the clinic in order to obtain medical services under false pretenses or to avoid paying valid charges payable to the clinic, those misrepresentations may be construed as probable fraud. In cases of probable fraud, the clinic may:
  • File a theft report with the appropriate authorities
  • Provide all appropriate supporting documents and information regarding the fraudulent activity to investigating authorities
  • Immediately refer to a collection agency for legal action through Small Claims Court in the event of any fradulent activity