Instructions

Insurance & Payments

Billing Policy

1. Co-payments are due at the time of service/registration. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, DISCOVER, AND AMERICAN EXPRESS.
2. The office charge for a returned check (NSF) is $25.
3. It is the patient's responsibility to ensure that referrals submitted are valid for the correct number of services/dates of treatment.
4. It is the patient's responsibility to ensure that proper referrals are submitted to Dr. Kafka's office at the time of service.
5. If required, it is the patient's responsibility to submit a separate referral/authorizations for follow-up visits.
6. This office will not accept back-dated referrals.

All bills will be forwarded to your Primary insurance carrier. Participation does not guarantee payment in full. Deductibles, co-payments and/or co-insurance amounts will be determined by your insurance carrier upon receipt of a claim. If the insurance payments are issued directly to the patient, the patient will be billed and is responsible to remit payment directly to the provider.

I understand and agree to the above. I also understand that without a referral, if one is required by my carrier, or if I have no insurance, I will be billed for the visit directly. I further understand that I will be responsible to seek reimbursement from my insurance carrier.