Tricity Family Medicine & Urgent Care Clinic, PLLC

107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666 Fax: 919-363-8668


Your medical insurance policy is a contract between you and the insurance carrier. Your coverage, the requirements for pre-authorization, deductibles, co-payments and co-insurance are all defined in your policy and their verification is your responsibility.

You are responsible for all charges from the date of service_ As a courtesy, we will file all claims for our service with your insurance company. Make sure that all the information you provided is accurate and up-to-date If we have not received payment from your insurance company within 60 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid whether by you or by your insurance company.

We require all patients to sign a copy of our Patient Registration/ Demographic Form that assigns insurance benefits to be paid directly to Tricity Family Medicine & Urgent Care Clinic, PLLC. In the event your insurance company sends payment directly to you, it is your responsibility to sign the check over to Tricity Family Medicine & Urgent Care Clinic, PLLC.

We cannot waive any co-payments, deductibles or coinsurance amounts defined as patient responsibility under the terms of our contract with these various plans If your insurance plan requires a co-payment, such co-payment is due at the time of service; otherwise, your appointment may have to be cancelled and rescheduled. For your convenience, we accept Visa, MasterCard, Discover, or personal checks.

NO Retro Billing - Please note if you have multiple health insurance policies, it is your responsibility to provide us with accurate information about each of your policy in the right order. Failure to do so, may lead to payment reversal from your insurance eventually and you will be responsible for outstanding balance at self-pay rate.

Missed Appointment Fee - Our office requests that if an appointment needs to be cancelled that we receive notice no later than 4 hours prior to the appointment. We charge $15.00 for a 'no show' appointment, to be collected on or before your next appointment.

Form Fee - Please note we do charge Form Fee(varies) for documents that require additional Physician time outside office visit.

Returned Checks - There is a fee (currently $25) for any checks returned by the bank.

NO Workers Compensation - Please note we DO NOT file workers compensation claims.

After Hrs/Weekend/Holiday Charges - There will patient responsibility of $25 for after hours if not covered by insurance. After hours are considered M-F after 5pm and weekends and holidays that we are open.

Starting July 20, 2011, balances are due within 30 days of when the bill is issued. Bills will be issued after the insurance carrier pays its portion of the bill. Any outstanding balance that is 60 days overdue, a $15 Service Charge will be imposed to help cover the costs involved in continuously sending overdue bills. For any outstanding balance that is 90 days overdue, your account may be forwarded to a collections agency and be subject to a collection fee equivalent to 50% of the unpaid bill.

By signing below, I acknowledge I have read, understood and received a copy of Fees, Payment & Billing policy.

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