Financial Policy

With Insurance

1. Patients are responsible to know the coverage of their insurance plan including; co-pays, deductibles, referral requirements, prior authorizations and provider participation.
2. A valid insurance card is required at each visit.
3. Insurance co-pays and\ or deductibles are expected to be paid at the time of service.
4. Jordan River Women’s Health, P.C. will file claims to your insurance company within one week of service date.
5. Patients are responsible for keeping account in good standing.
6. Patients are responsible for any balances denied by insurance company and that are not paid within 30 days.

Without Insurance

1. Gynecological patients will be asked to pay in full at time of service. When paying in full at time of service you will receive a 20% discount.
2. Obstetrical patients need to sign a Financial Agreement to set up monthly payment arrangements to pay for delivery.
3. Patients will be responsible for keeping account in good standing.
4. If there are circumstances that keep you from paying account in full within 30 days you will need to contact our billing department at 801-561-2227 to make payment arrangements.

Terms and Conditions

Patient agrees to pay a return check fee of $35 on any checks that are returned. By signing below, I agree to pay all amount(s) owed, in full within 90 days from the date of service. I understand that it is my responsibility to provide my correct/ updated insurance and demographic information and that this office will bill my insurance as a courtesy to me. However, regardless of insurance coverage, I agree that it is and shall remain my responsibility to pay all amounts owing as set forth herein. In the event any amount(s) is/are referred to a third party debt collection agency, I agree that in addition to any other amount(s) allowed for by law, (such as interest, court costs, attorney’s fees, etc.) I will also be responsible for a collection fee up to 40% of the principal amount(s) owing as allowed by Utah Code Annotated, sec.12-1-11. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual for whom I have legal responsibility whether such amount(s) are incurred today or thereafter.

I hereby consent to being contacted by telephone at any telephone number (including but not limited to wireless/cellular phone numbers) provided by me or anyone associated with me or acting on my behalf to Jordan River Women’s Health or anyone acting on its behalf. I understand and agree that such calls may be initiated by Jordan River Women’s Health or any of its affiliates, agents, contractors or assigns, including but not limited to third-party collection agency(ies), and that the methods of contact may include the use of text messages—some or all of which may result in data charges. I also consent to receiving e-mails at any e-mail address provided by me or anyone associated with me or acting on my behalf.

I have read the above financial policy and understand the terms of this policy. I agree to be responsible for payment of all services rendered. I authorize release of all medical information necessary to process all insurance claims relating to services rendered.

You will be required at your first visit to have valid insurance information. If you do not have insurance you will need to place a $300 deposit on your account. At your second visit if you are still without insurance you will be required to sign a Financial Agreement and make a monthly payment amount towards your Obstetrical services. If you have neither of the above you will need to reschedule your appointment to a later date.

Ultrasounds and laboratory fees are not included in the “global charge” and will need to be paid at the time of service.

I have read and understand the above OB policy in its entirety.