Notice of Privacy Practices

Shirley A. Anain, M.D.

 4949 HARLEM RD SUITE 302 | AMHERST NY, 14226 | (716) 838-1333

 

Written Financial Policy

Thank you for choosing Shirley A. Anain, M.D.  Our primary mission is to deliver the best and most comprehensive care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

You can choose from: 

- Cashiers heck, Money Order, Visa, MasterCard, American Express or Discover Card

- Cash, Personal Check (NOT accepted for surgery)

- Care Credit –pamphlets are available throughout the office or online at www.carecredit.com

o   Option 1: No Interest if Paid in Full within 6, 12, 18 & 24 Months**   Subject to credit approval. 

o   Option 2: 14.90% APR and Fixed Monthly Payments Required Until Paid in Full over 24, 36 & 48 Months**  Subject to credit approval. 

o   Allow you to pay over time

o   No annual fees or pre-payment penalties

Copayments & Coinsurance

Your copayment is due at the time of service – it is your agreement with your insurance carrier. Any outstanding balance on accounts are to be paid prior to being seen unless other arrangements have been made.  We reserve the right to decline your visit without the required payment.

Deductibles

If you have a deductible with your insurance plan, as per your insurance contract, you are required to pay for a portion or all of your medical services.  Because electronic health insurance verification systems are not always current, your claim will be filed and you will be billed for any deductible payments due.  Payment is due within 30 days. 

Credit Card Payments by Patients/Other Cardholders

If a payment is made on my behalf by another cardholder, in the event of a dispute, I understand that it is ultimately my responsibility to pay the fees in full to Shirley A. Anain, MD. I authorize Shirley A. Anain to disclose my information to the credit card company if for any reason there is a credit card dispute.

Insurance Information/Assignment of Benefits

Patients are required to provide Shirley A. Anain, M.D. with current and accurate insurance information at every visit.  Failure to provide us with accurate information will result in you being responsible for the bill.  By signing below, you authorize Shirley A. Anain, M.D. to furnish information to insurance carriers concerning your illnesses and treatments and hereby assigning all payments for medical services rendered to you by Shirley A. Anain, M.D.  Furthermore, you will be held responsible for any amount not covered by your insurance plan. Photo Identification -Due to the threat of Identify Theft, Photo Identification is required at the time of your initial visit.

Payment Options/Cancellations for Surgery

Self Pay/No Insurance Coverage: Payment is expected in full no later than 4 weeks prior to your procedure, otherwise your procedure may be cancelled.  You are welcome to make partial prepayments.

Cash and Personal Checks are NOT accepted for surgeries.

If you choose to cancel and not to reschedule the surgery, you will receive a refund. 

If there is an outstanding balance on your account, this will be deducted from the refund amount.  

If a Breast Augmentation is cancelled within 2 weeks of the surgery, there is a $100 fee due to the charges associated with the implants. 

With Insurance Coverage:   We are happy to work with your insurance carrier and bill them directly for your treatment.  If your insurance plan includes a deductible or coinsurance, a prepayment is expected no later than 4 weeks prior to your procedure.  We reserve the right to reschedule if the prepayment is not received in a timely manner.  Any overpayments of a deductible/coinsurance will result in a refund.

Self Pay Payments for Injections

Private payment for injections are due no later than 2 weeks prior to the injection to hold your appointment.  Otherwise, if prepayment is not received, your appointment may be cancelled/rescheduled to accommodate other patients that may be waiting.

Unpaid Balances

If for any reason, you maintain an unpaid balance on your account, fail to work out a payment arrangement with us, or fail to keep your payments current, after 120 days, your account will be turned over to our Collection Agency and proceedings will begin.  Accounts sent to collections will not be permitted to make further appointments.

Returned Check Fees

 A $35.00 fee will be assessed for all checks returned for insufficient funds. I understand that I am over the age of 18 and it is my responsibility to pay any deductible, coinsurance or other balance which is not paid by my insurance.  I acknowledge that copays are expected at the time of service unless otherwise arranged. I have read and agree to all of the above policies.  I understand and agree that such terms may be amended by the practice from time to time, and that I will be notified of any changes.I hereby give my permission to Shirley A. Anain, M.D. to render evaluation, administer treatment or perform such procedures as may be necessary for diagnosis and treatment.