We believe the best healthcare outcomes are based on mutual trust between patient and physician. We
believe patients and families are partners in ensuring that the best possible care is provided in a healthful, safe
environment. We count on you to participate in your care in the following ways:
- To the best of your knowledge, provide accurate and complete information about your present
symptoms, past illnesses, allergies, hospitalizations, medications and other matters relating to your
- Ask questions if you do not clearly understand the proposed plan of care and what is expected of you.
- Arrive at least 10 minutes before your appointment to ensure you are seen on time.
- Keep appointments. When you are unable to do so for any reason, notify the office reception staff in
advance. A $25 fee may be applied for any visit missed without proper notice. Excessive missed
appointments may result in discharge from the practice.
- Treat other patients and staff with consideration and respect.
- Be respectful of other patients’ right to privacy.
- Be honest with the doctors & other health-care workers.
- Follow the treatment plan agreed upon.
- Provide accurate insurance information and promptly pay balances not covered by your insurance.
- Understand the requirements of your own health insurance. (We will do our best to assist you as we
are able however, it is virtually impossible for us to keep all of the different health plans straight, but
we sure try!)
- Pay your co-payment at the time of your appointment.
- Understand how your pharmacy plan works.
- If you have a life threatening situation, call 911 or go to the nearest emergency room.
Mansfield Family Practice will try to do everything we can to accommodate you and your family. In an effort
to set reasonable expectations, Mansfield Family Practice will:
- Introduce ourselves.
- Greet you in a pleasant, professional manner.
- Take you to a neat, orderly exam room and be prepared for your exam.
- Answer your questions or let you know where you can get answers.
- Fill or refill prescriptions within fourty eight (48) hours. Refills may take longer if they are called in after hours or on weekends.
- Process any requested forms you may need for school/camp physicals, disability, FMLA, etc. within 7
days. A form completion fee may apply of $25
- Do our best to find you a suitable appointment date and time. Please note that most forms you need
for schools or work require an examination
- Provide prompt and accurate billing
- Keep all your records and communications concerning care and treatment confidential.
- Handle routine medical questions during normal business hours. Every effort will be made to return
your call in a timely manner, however, you may need to be seen in our office to properly diagnose and
treat a problem. We can only truly treat all medical problems in person.
Because some of our patients have had questions regarding patient and insurance responsibility for services
rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may
have, and sign in the space provided. A copy will be provided to you upon request.
- Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan
we do business with, payment in full is expected at each visit. If you are insured by a plan we do
business with, but don’t have an up-to-date insurance card, payment in full for each visit is required
until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please
contact your insurance company with any questions you may have regarding your coverage.
- Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service.
This arrangement is part of your contract with your insurance company. Failure on our part to collect
co-payments and deductibles from patients can be considered fraud. Please help us in upholding the
law by paying your co-payment at each visit.
- Non-covered services. Please be aware that some – and perhaps all – of the services you receive may
be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must
pay for these services in full at the time of visit.
- Proof of insurance. All patients must complete our patient information form before seeing the doctor.
We must obtain a copy of your driver’s license and current valid insurance to provide proof of
insurance. If you fail to provide us with the correct insurance information in a timely manner, you may
be responsible for the balance of a claim.
- Claims submission. We will submit your claims and assist you in any way we reasonably can to help get
your claims paid. Your insurance company may need you to supply certain information directly. It is
your responsibility to comply with their request. Please be aware that the balance of your claim is your
responsibility whether or not your insurance company pays your claim. Your insurance benefit is a
contract between you and your insurance company; we are not party to that contract.
- Coverage changes. If your insurance changes, please notify us before your next visit so we can make
the appropriate changes to help you receive your maximum benefits. If your insurance company does
not pay your claim in 45 days, the balance will automatically be billed to you.
- Nonpayment. If your account is past due, you will receive a letter stating that your account may be
heading to collections. Please be aware that if a balance remains unpaid, we may refer your account to
a collection agency and you and your immediate family members may be discharged from this practice.
If this is to occur, you will be notified by regular and certified mail.
- Missed appointments. Our policy is to charge for missed appointments not canceled within a
reasonable amount of time. These charges will be your responsibility and billed directly to you. Please
help us to serve you better by keeping your regularly scheduled appointment.
- Form Completion Fee. We require payment for the completion of forms done on your behalf outside
of an office visit. These charges are to be paid at the time of service
- Mansfield Family Practice is committed to providing the best treatment to our patients. Our prices are
representative of the usual and customary charges for our area.