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Financial Terms And Conditions

Please carefully review with your health insurance plan in advance whether the proposed or desired treatment procedures are covered by your health insurance.

Please note that payment is due at the time services are rendered. The fees charged for your procedure(s) do not include any potential future costs, in the event you choose to have or require additional procedures to complete your care and treatment with us.

Thank you for your cooperation and understanding.

Deductible, Co-Insurance, and Co-Payment

If you have health insurance which covers the treatment procedure(s), you are responsible for a necessary deductible, co-insurance, and co-payments. Your co-payment is due at the time of service, and co-insurances are settled once the claim is adjudicated. If your deductible has not yet been met, payment may also be required at the time of service.

Non-Covered Services

If the services provided are not covered by your health insurance carrier, you will be responsible for the necessary payments for those charges not covered. Your e-signature below constitutes agreement to pay for such services.

Out-of-Network Services

As an out-of-network provider and with the potential of utilizing an out-of-network outpatient surgery facility, none of the parties involved have a contract with your health insurance carrier. As a result, you may be financially responsible for a higher share of the fees than a provider, laboratory, or facility within your network. Your signature below constitutes an agreement to pay for the applicable portion of the out-of-network fees.

Insurance Submission

The insurance process will begin once your procedure has been completed. There are three entity claims that will be submitted to your insurance on your behalf – physician, facility, anesthesia. The insurance may take between sixty and ninety days to finalize all three claims, and possibly longer if an appeal is necessary.

Member Appeal Representation Authorization

In the event, your claim is denied and/or processed by your insurer but below your applicable level of benefits, you request and grant authorization to Caliber Medical P.C. and its agents, contractors, and employees to represent you and act on your behalf regarding your medical health claim determination. This authorization will expire upon the resolution of the appeal.

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Caliber Pain™

635 Madison Avenue 14th Floor
New York, NY 10022

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