Financial Policy for Self-Pay Patients

GEM Neurology Financial Policy for Self-Pay Patients

Welcome to GEM Neurology! We are committed to providing high-quality care and ensuring transparency in our billing and payment policies. This document outlines our financial policy for patients who do not have medical insurance and are opting to self-pay for services. Please read carefully, to understand these terms.

1. Self-Pay Visit Fees

For self-pay patients, the out-of-pocket costs for services at GEM Neurology are as follows:

• New Patient Visit (CPT 99205): $199

• Established Patient Visit (CPT 99215): $149

Payment is due in advance at the time of scheduling and applies to both in-person and teleneurology visits.

2. Payment Requirements

• Advance Payment: Full payment for your scheduled visit is required in advance to confirm your appointment. Payments can be made via credit card, debit card, or our online payment portal (if applicable).

• Scheduling Options: Once payment is received, appointments can be scheduled online, via phone, by mail, or in person at GEM Neurology’s front desk.

• Good Faith Estimate: Upon request, we provide a Good Faith Estimate for any additional services that may be necessary during your visit to comply with federal guidelines.

3. Cancellation and Rescheduling Policy

We understand that circumstances may arise which require you to cancel or reschedule your appointment.

• Cancellations: To receive a full refund, please cancel your appointment at least 24 hours before your scheduled time.

• Rescheduling: If you need to reschedule, please notify us at least 24 hours before your appointment. We will apply your prepayment to the new appointment date.

• Late Cancellations and No-Shows: Cancellations made within less than 24 hours of the appointment and no-shows will incur a $25 fee. This fee will be deducted from your prepayment, and the remaining balance will be refunded to you.

4. Late Arrival Policy

To maintain our schedule and ensure all patients receive timely care, we have implemented the following policy for late arrivals:

• Established Patients: Arriving 15 minutes or more past the scheduled appointment time will require rescheduling. This appointment will be counted as a no-show unless a legitimate emergency caused the delay.

• New Patients: Arriving 25 minutes or more past the scheduled time will require rescheduling, following the same no-show policy.

• Arrival Recommendations: To ensure smooth check-in, we recommend that all patients arrive 15 minutes priorto their scheduled appointment time.

5. Refund Policy

• Full Refunds: Cancellations made 24 hours or more before the scheduled appointment are eligible for a full refund.

• Partial Refunds for Late Cancellations: If you cancel less than 24 hours before the appointment, a $25 fee will apply, with the remaining balance refunded.

• Payment Refund Method: Refunds will be processed back to the original payment method within 7–10 business days.

6. Compliance with Anti-Discrimination Laws

GEM Neurology upholds all federal and state laws prohibiting discrimination. We do not discriminate in our services or policies based on race, color, religion, sex, gender identity, sexual orientation, age, national origin, disability, or any other protected characteristic. Our self-pay policies apply uniformly to all patients opting to self-pay.

7. Patient Acknowledgment and Signature

By signing below, you acknowledge and agree to GEM Neurology’s financial policy for self-pay patients. You understand the advance payment, refund, cancellation, rescheduling, and late arrival terms, as well as your rights under anti-discrimination laws.

Patient Name: ________________________________
Patient Signature: _____________________________
Date: _________________________________________

Submitting This Form

Please return this signed form to GEM Neurology. You may submit it online, by mail, or in person. We require this signed form on file before scheduling your appointment.