Patient Financial Policy - Mercy Medical Center Sioux City

Patient Financial Guidelines
What you should know about paying for your healthcare services.
Thank you for choosing Mercy Medical Clinics for your healthcare needs. Bills for
services provided by healthcare professionals, hospitals, and clinics can be confusing. We
hope the enclosed information will answer some of the questions you may have regarding
your financial responsibility. Please read it, ask us any questions you may have, and sign
in the space provided below. A copy will be provided to you for future reference.
Insurance: To help you get the most from your health insurance plan, we encourage you to
be come familiar with your insurance plan requirements before seeking care. Failure to bring
in a current, up-to-date insurance card requires payment in full at the time of service, for each
visit, until we can verify your coverage. As a courtesy, we will submit claims to your
insurance company and will assist you in receiving the full benefit of your health insurance
plan. Always be prepared to supply the social security numbers for both the patient, as well
as the policyholder. Your insurance company may need you to supply certain information
directly. It is your responsibility to comply with their request in a timely manner. If your
insurance changes, please notify us before your next visit so we can make the appropriate
changes in our system.
We participate in most insurance plans, however if you are not insured by a plan we
participate in, you may have a higher out of pocket expense. Many health insurance plans
limit the payment for medical services based on their own “usual, customary, and reasonable”
(UCR) allowances. If we do not have a contract with your insurance company, the difference
between the billed amount and the UCR amount will be billed to you.
Co-payments, Coinsurance, and Deductibles: Your insurance company requires us to
collect co-payments, co-insurance, and/or unmet deductibles at the time services are
rendered. This arrangement is a contract you have with your insurance company. Please
help us in upholding the law by taking care of your responsibility at each visit. Failure to do
so may result in a service charge, to help cover our billing costs. Whoever brings a child to
the office is responsible for paying their bill, regardless of who is legally responsible for the
child’s medical care.
Appointment No Shows: If you anticipate that you may be unable to make a scheduled
appointment, please notify our office at least 24 hours in advance, so that another patient in
need of an appointment might be seen. Failure to notify us may result in a service charge.

Non-covered Services: Some services may be non-covered by your health insurance plan.
You are responsible for non-covered services at the time of service. An example of this
would include cosmetic procedures. In some cases, we may send lab work or specimens to
an outside lab for processing. As a result, your physician visit may result in a bill from that
facility as well.
Workers’ Compensation: If your healthcare needs are the result of a work related injury, we
will bill your employer or your employer’s liability carrier. We also will ask for your health
insurance information in the event that Workers’ Compensation denies the claim. You are
responsible for ensuring that your workers’ compensation company will cover the services
you receive, prior to the services being rendered.
Financial Assistance: As a part of our mission and philosophy, we are committed to assist
all individuals in receiving needed healthcare, and meeting their financial obligation resulting
from that care. For patients who are experiencing severe financial difficulties that do not
qualify for outside resources, a financial assistance program is available. To request an
application for Financial Assistance, please call the clinic, or the business office.
How to Contact Us: If you have any questions regarding your account, you may contact us
by calling (712) 279-5830, or toll free at (800) 491-0038.
I have read and understand the payment policy, and agree to abide by its guidelines.
Failure to meet your financial obligation may result in the account being referred to an
outside collection agency and termination from all Mercy Medical Services clinics.
______________________________________ _______________
Signature of patient or responsible party Date