Sierra Rheumatology Inc.

2207 Plaza Drive, Suite 100,  Rocklin, CA 95765

Telephone: (916) 677-4744 Fax: (916) 781-2029 

www.sierrarheumatology.com

Financial Policy

As a courtesy, Sierra Rheumatology verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of Sierra Rheumatology that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. At the conclusion of your visits with us you may be billed for any outstanding balances.

If you are covered by health insurance with Rheumatology benefits, we will be happy to bill your insurance. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by our plan.

Although we are contracted with most insurance carriers, your services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred; your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.

We highly recommend you also contact your insurance carrier and check into your coverage for Sierra Rheumatology. Do not assume that you will not owe anything if you have more than one insurance policy.

No Show and Cancelations, I understand there is a $ 50.00 charge for No Show and Cancelations not made 24 hours in advance for established and $100.00 for New Patients.

There is $ 25.00 fee for any check that is returned by your bank.

I have read and understand the above financial policy for payment and fees:

Financial Policy

SIGNATURE ON FILE FORM FOR MEDICARE CLAIMS (ONLY FOR MEDICARE PATIENTS)

I request that payment of authorized Medicare benefits be made on my behalf to Sierra Rheumatology for any services furnished by a Dr. Dhillon c/o Sierra Rheumatology. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

I have read and understand the signature on file for Medicare: