Family Care USA PLLC
OUR PRACTICE FINANCIAL POLICY
We are dedicated to providing you with the best possible care and service, and regard your
understanding of our financial policy as an essential element of your care and treatment. To assist
you, we have the following financial policy. If you have any question please feel free to discuss
them with our staff. Unless other arrangements have been made in advance by either you or your
health coverage carrier, full payment is due at the time of service.
We have made prior arrangements with many insurers and other health plans. We will bill those plans
with which we have an agreement and will collect any required co-payment at the time of the
service. The co-payment will be collected when you arrive for your appointment. In the event your
health plan determines a service to be not covered, you will be responsible for the complete
charge. In that event we will bill you and payment is due upon receipt of that statement.
If you have insurance coverage with a plan with which we do not have a prior agreement, we will
prepare and send the claim for you, on an unassigned basis. In this case, your insurer will send
the payment directly to you. Therefore charges for your care and treatment are due at the time of
We will also bill your health plan for all services we provide in the clinic. Any balance due is
your responsibility and is due upon receipt of a statement for our office. Please be advised that
there will be a $36 service charge for any returned checks.
For all services rendered to minor patients, the adult accompanying the patient is responsible for
In order to provide the best possible service and availability to all our patients, it is our
policy to charge our office visit fee for any appointments not canceled at least one day prior.
Please call us early as possible if you know you will need to reschedule your appointment.
CONSENT TO TREAT
I consent to treatment as necessary or desirable to the care of the patient named below, including
but restricted to whatever drugs, medicine, the performance of operations, and conduct of laboratory,
x-ray, or other studies that may be used by the attending physician, his nurse or qualified
designate. I further understand that the qualified designate in the same case will be the assistant
to the Primary Care Physician, all also called an MA. I also acknowledge full responsibility for
the payment of such services and agree to pay for them, in full, at the time of service. If the
physician must use a collection agency/attorney or court to collect its charges, then I will pay
reasonable_attorney fees and costs incurred in collecting the same regardless of insurance coverage. I
hereby authorize payment directly to Dr. Hina Zaman of the medical expense benefits
otherwise payable to me but not to exceed my indebtedness to said Physician on account of the
enclosed charge. I have read and understood the financial policy of the practice and I agree to the
bound by its terms that such terms may be amended from time to time by the practice.