Thank you for choosing Gastroenterology Health Partners, PLLC as your health care provider. Please understand that payment of your bill is considered a part of your treatment. We welcome the opportunity to discuss any aspect of our Financial Policy with you or your legal/authorized representative.

INSURANCE: Your insurance coverage is a contract between you and your insurance company, and it is important that you understand the provisions of your policy. If you are covered by any private insurance carrier or government sponsored program, you must present your current insurance card and photo ID prior to services being rendered. If your card is not available, your appointment will be rescheduled.

Although Gastroenterology Health Partners, PLLC will file an insurance claim as a courtesy on your behalf, it cannot guarantee payment of claims and it cannot accept responsibility for collecting payment or for negotiating settlement on a disputed claim. A reduction or rejection of your claim by your insurance company does not relieve you of your financial obligation; professional services are rendered and charged to the patient, not the insurance company. Patients are responsible for payment in full on all services rendered. You must verify whether your insurance plan requires a referral and/or authorization services, and it is your responsibility to obtain the referral and/or authorization. Your appointment will be rescheduled should a referral and/or authorization not be obtained prior to your appointment date. If your insurance company rejects your claim or pays only a portion of your bill, any contact or explanation should be issued to you, the policyholder. Not all services are a covered benefit in all insurance plans.

COPAYMENTS, DEDUCTIBLES, & NON-COVERED SERVICES: All copayments, deductibles, and payment for non-covered services are due at the time services are rendered, and Gastroenterology Health Partners, PLLC requires a valid credit card placed on file for payment of these services. Credit card information is collected and/or confirmed at time of scheduling. If Gastroenterology Health Partners, PLLC does not participate with your insurance plan or if you do not have health insurance coverage, payment in full is due at the time all services are rendered. If you are unable to pay your co-pay, your portion of your deductible or any self-pay fees, your appointment will be rescheduled.

COMMUNICATION: Communication regarding your account may be necessary to ensure your account remains in good standing. The undersigned provides authorization to receive communication regarding his/her account from Gastroenterology Health Partners, PLLC, its affiliates, and/or business partners through multiple methods to include, but not limited to, postal mail, voice call, auto-dialer, prerecorded voice messages, SMS messages, and email to all landline phone numbers, cell phone numbers, and/or email addresses provided.

NON-PAYMENT & ACCOUNTS REFERRED TO COLLECTIONS: If your account becomes delinquent and you have not responded to our collection efforts, your account will be turned over to an outside source for collection of the full balance due, and at which time you will be responsible for all additional fees related to that expense, including all applicable court costs and legal fees; these fees will be charged in addition to any existing overdue balance. If you cannot pay your balance in full, your appointment will be rescheduled until your balance has been paid or a payment plan is arranged with our billing office. Please contact our billing team at 502-888-1988 for assistance. Failure to pay balances due or to make payments corresponding to a payment plan may lead to your dismissal from the practice.

RETURNED CHECKS: All returned checks are subject to a service fee. Returned check fee(s) must be paid in full prior to scheduling future appointments.

MISSED APPOINTMENTS: To better serve all our patients, 24-hour advanced notice is required prior to rescheduling or cancelling an office visit, and 48-hour advanced notice is required for procedures. Subject to insurance guidelines, a $25.00 fee may be incurred for office visits which are rescheduled or cancelled without 24-hour advanced notice, and a $100.00 fee for procedures rescheduled or cancelled without 48-hour advanced notice. Late arrivals to a scheduled appointment greater than 15-minutes may also be subject to a missed office and/or procedure appointment. Cancellation charges are not covered or paid by any insurance company, and therefore, charges will be billed directly to the patient. All fee(s) must be paid in full prior to scheduling future appointments. If more than (3) appointments are collectively MISSED or CANCELLED without advanced notice, dismissal from the practice will occur.

MINOR AGE PATIENTS: Treatment for unaccompanied minors will be denied unless charges have been pre-authorized prior to date of service. Parents, guardians, and adults accompanying a minor are responsible for payment in full.

CAPSULE ENDOSCOPY SERVICES: If indicated by your provider, you may receive a patency or “test” capsule prior to a capsule endoscopy procedure. Patency capsules are not covered by insurance and the cost of the capsule will be billed to you as a non-covered service.

WORKMAN’S COMPENSATION, AUTOMOBILE ACCIDENTS: Full payment is due at time of service. Although claims for these services will NOT be filed on your behalf, we will provide you with information you may need to file a claim for services independently.

FORM COMPLETION: Disability, FMLA, Life Insurance and other forms often require review and completion of detailed medical history by our clinicians. Please allow (10) business days for completion of these forms. Additional fees apply and payment must be made in full upon submission to our office.

MEDICAL RECORDS REQUESTS: Requests for copies of medical records will be processed upon receipt of a completed Medical Records Request Form and will be published to the Patient Portal (gPortal). Per Kentucky state law, there is no charge for the first requested copy for Kentucky patients. Please allow us (10) business days to complete all requests. Per Indiana State law, an additional $10.00 rush fee will be assessed for requests needed within (2) business days and a $20.00 fee for certification of records.

FMLA, Disability, and Miscellaneous Form(s)$35.00
Missed Office Appointment – Fee assessed if appointment not cancelled within 24 hours$25.00
Missed Procedure Appointment$100.00
Returned Check$30.00
Medical Records Release – Published to gPortal for personal health recordNo Charge

AFFILIATIONS: Please be aware that you may receive statements from multiple entities after having a procedure. Your physician may have shareholder interest in procedure centers not otherwise affiliated with Gastroenterology Health Partners, PLLC, and you may receive separate statements for fees associated with professional services, facility, pathology, infusion services, or other diagnostic testing. If you have a procedure performed by any of our physicians at an ambulatory surgical center or a hospital, you will receive a bill from that facility for its facility fee as well as from Gastroenterology Health Partners, PLLC for professional and ancillary services which apply.

I have received, reviewed, and understand the Gastroenterology Health Partners, PLLC financial policy and I agree to be bound by each of its terms and conditions. I also understand and agree that such terms may be amended by the practice from time to time. I understand that I am financially responsible for all charges regardless of payments made by my insurance. I hereby authorize Gastroenterology Health Partners, PLLC to release medical information to my insurance company to secure payment of benefits. I also authorize the use of this signature on all insurance submissions and as authorization for payments to be sent to Gastroenterology Health Partners, PLLC. This signature authorizes release of medical records to any physicians or health care facility when referred or requested by them for continuity of care. I voluntarily consent to medical care including the routing of diagnostic testing, surgical procedures, and additional medical treatment.

Patient Forms Updated

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Permission to Leave Messages: I authorize GHP, PLLC to contact me and leave detailed health and billing information on the voicemail of the below listed phone numbers.
Permission to Disclose Medical & Billing Information: I authorize Gastroenterology Health Partners, PLLC (Gfll', PLLC) to share and/or disclose medical and billing information to family and/or individuals listed below who are directly related to my care or responsible for payment of services related to my care.
Phone Number
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