Welcome, and thank you for choosing Gary Bucher M.D. & Associates/(ADCmidWest), the center of excellence where we truly care about your anal health.

The providers and staff at ADCmidWest understand that our primary purpose is to provide you with the highest quality of care. We pledge to do this, and to do our part in controlling medical costs. We believe that part of a good health care practice is to establish and communicate a financial policy to our patients. Your understanding of our Patient Financial Policy is an essential element of your care and treatment. Please read the policy and sign below. A copy will be maintained in your chart and may be provided to you upon request. To ensure that you have received our most current Patient Financial Policy, we will ask you once a year to sign the most current version, or whenever our Patient Financial Policy has been updated.

What type of payments are due at Time of Service:

• Co-pays that are required by your health insurance policy.
• If you have no health insurance and/or are self-pay, charges or any balance incurred are due in full at time of service.
• If you or any of your dependents have an outstanding/past due balance, we will take payment of that balance at this time.

Charges incurred for services rendered by ADCmidWest are your responsibility, regardless of insurance coverage. Per your health insurance policy, you may still incur charges even if you were notified that the services we had provided to you are covered. When your health insurance company says that services we provided are covered, that means that procedure and diagnosis codes we billed to your insurance are going to be considered for payment by your policy. Your health insurance policy determines what your personal financial responsibility will be for services rendered, i.e. your annual deductible, out-of-pocket or co-insurance amounts.

Assignment will be accepted for all insurances with which our practice participates.

It is your responsibility to provide this office with your current/accurate health insurance information, and to notify us before any appointment of any changes in your health insurance coverage. It is also important that you inform us of any changes to your contact information, prior to any appointment, i.e., home or mailing address, e-mail address, phone numbers. Please also notify our office if you are enrolled in any state or federally sponsored insurance plans. In the event our office is not informed before care is rendered, you will be responsible for any charges that are denied. To verify if ADCmidWest is in network with your health insurance plan, please call the patient customer service number on the back of your insurance card and ask if Bucher Medical Services is in network. As a courtesy to you, we will file your medical claim with your health insurance company. Any amount not covered by your insurance (co-pay, co-insurance, out of pocket, deductible or not covered services), will be your responsibility.

Patient Statements:

Once we have received the Explanation of Benefits (EOB) from your health insurance company, we will reconcile that information with the corresponding Date of Service (DOS) on your ADCmidWest account. If you have signed up to receive communication from your health insurance company, you will also receive a copy of your EOB either via mail or electronically. If your health insurance company determines that you will have a financial obligation to us for a certain DOS, you will receive a patient statement from us. Any balances that are not paid after 30 days from the date of the ADCmidWest patient statement will be automatically charged to your credit card on file.

We accept the following types of payments:

• Cash
• Personal Check - There is a $35.00 fee for checks returned due to insufficient funds
• Visa/Master Credit Card – all credit card payments will be charged a 3.5% credit card processing fee
• CareCredit

If you would like to avoid the 3.5% credit card processing fee, please mail us your payment in form of a personal check to our mailing address at:

Bucher Medical Services

3023 N. Clark St., #200

Chicago, IL 60657

APPOINTMENT ADJUSTMENT FEE (AAF/Late Cancellation/No-Show):

The following AAF applies to ALL patients in ALL circumstances when there is a change to the schedule with less than a 48-hour notice. The AAF also applies to appointments made within 48 hours of the scheduled appointment.

• $50.00 general or new patient appointment
• $100.00 treatment appointment

Patients who fail to show up or cancel/reschedule an appointment without a 48-hour notice will be charge the appropriate appointment adjustment fee (plus 3.5% credit card processing fee). We will charge the credit card on file and e-mail a receipt to the e-mail address on file. If your credit card on file is declined, no future appointments can be scheduled until no-show fees are paid. Appointment reminders are a courtesy, however, not receiving an appointment reminder is not a valid reason to miss an appointment. It is your responsibility to keep track of your scheduled appointment(s). Should you arrive too late for your scheduled appointment, it will be at ADCmidWest’s discretion if you can be seen or if you need to re-schedule your appointment.

Collections: Your payment of your statement balance is due upon receiving your patient statement. Your balance is considered past due after 30 days from the date of the ADCmidWest patient statement. Past due accounts are subject to collection proceedings. After your account becomes past due, all amounts will be due at that time and we will attempt to run the credit card on file. If we are unable to run the card on file, we will send an additional statement. After 90 days your account will be turned over to our collection agency and you will be responsible for all collection fees and fees that the practice incurs as a result. We reserve the right to refuse service to any patient that has been placed into collections.

Credit Card(s) on File: Your credit card information is required when scheduling any appointments. This information is encrypted and stored securely online. Any balance owed by you will be charge to your credit card on file the business day after your Patient Statement Due Date. You may access your billing statements through the Patient Portal. A copy of your credit card receipt will be emailed to you. Please note that this will not compromise your ability to dispute a charge or your insurance company’s determination of payment.

Credit Card Charge Disputes: Credit card charge disputes must be brought to the attention of the ADCmidWest Director of Operations prior to disputing it through the bank/credit card company. Any fees associated with a credit card dispute filed through the bank/credit card company that violates any of the terms outlined in this financial policy will become your sole financial responsibility and the credit card on file will be charged.

Should a patient opt to no longer receive medical care through Gary Bucher M.D. & Associates and should that patient request medical records to be transferred, we are hereby authorized by that patient to charge the credit card(s) on file for any outstanding balances. Gary Bucher M.D. & Associates reserves the right to refuse services to established patients who have not met their financial obligations such as outstanding past due accounts past 90 days or with balances over $200.00.

Any alternations to this policy by patients will not be accepted.

I HAVE READ AND UNDSTAND THE GARY BUCHER M.D. & ASSOCIATES PATIENT FINANCIAL POLICY AND AGREE TO ABIDE BY ITS TERMS.

Signing this Financial Policy means that you understand and agree to the AAF policy.