Register before your first visit.

Financial responsibilities

1. I understand that I am financially responsible for services rendered to me by the physicians and/or staff of Mark Jaffe, MD, PA. This includes providing current insurance information needed to submit claims to my insurance plan(s) on my behalf. Our office will submit claims only to primary and secondary insurance policies.
2. I understand that I am responsible for paying my co-pay, co-insurance or deductible at the time services are rendered.
3. I am aware if I have Medicare with no secondary insurance, I am responsible for keeping a credit card on file or paying the remaining 20% when services are rendered.
4. I understand that failure to provide current insurance information will result in my becoming responsible for payment of services rendered to me.
5. I authorize the physicians and/or the staff of Mark Jaffe, MD, PA to act as my designated representative as part of the appeal process should this be required by my insurance plan(s).
6. I authorize my insurance plan(s) to communicate with the physicians and/or staff of Mark Jaffe, MD, PA in all aspects of the submission and appeal process.
7. I understand that Mark Jaffe, MD, PA will put forth its greatest effort in collecting payment from my insurance plan(s). If they have exhausted all efforts, I will be responsible to pay for the services received.

Collections and associated fees

I understand services rendered to me by the physicians and/or staff of Mark Jaffe, MD, PA are my responsibility. Refunds which may be due will be returned via check mailed to your address on file. I understand that any account balance that is not paid within 60 days may begin our collection process. Balances remaining unpaid by 90 days may be reviewed and sent to a collection agency. If my account is sent to a collection agency, I will be responsible for all costs relating to the collection of my debt. This could include, but not be limited to, an additional 40% in fees assessed by the agency to which my account is sent.

Special accommodations

If you require a special accommodation for your appointment, you or your representative must notify our office at least one week (7 days) in advance of your appointment. If you are a new patient, notice must be provided at the time your appointment is scheduled. Under the Americans with Disabilities Act, “Providers are responsible for incurring all costs incurred for providing reasonable aid and cannot pass the charge onto the patient or their insurance company.” However, if you have requested an accommodation and you either do not show or do not cancel 24 hours prior to your appointment, you could be responsible for the cost incurred by the third party responsible for providing these services to you.

Patient expectations

We have a safe and healing environment. Foul language, aggression, and disrespect towards our staff is not acceptable. Verbal threats or inappropriate behavior will not be tolerated and could result in termination from our practice.