Thank you for choosing Dr. Wallin as your primary
care provider. Some of our patients have had questions regarding patient
and insurance responsibility for services rendered. We have been advised
to develop this payment policy. Please read it, ask us any questions you
may have, and sign in the space provided. A copy will be provided to you
1. INSURANCE. We participate in most insurance plans, including
Medicare. If you are not insured by a plan we do business with, payment
in full is expected at each visit. If you are insured by a plan we do
business with but you do not have an up-to-date insurance card, payment
in full for each visit is required until we can verify your coverage.
If we later receive a check from your insurer, we will refund any overpayment
to you. Knowing your insurance benefits is your responsibility. Please
contact your insurance company with any questions you may have regarding
2. CO-PAYMENTS AND DEDUCTIBLES. All co-payments and deductibles
must be paid at the time of service. This arrangement is part of your
contract with your insurance company. Failure on our part to collect co-payments
and deductibles from patients can be considered fraud. We will bill you
a $5.00 billing charge if co pay is not paid at time of visit. We accept
cash and checks as form of payment.
3. NON-COVERED SERVICES. Please be aware that some-and perhaps
all-of the services you receive may be non-covered or not considered reasonable
or necessary by Medicare or other insurers. You must pay for these services
in full at the time of visit.
4. PROOF OF INSURANCE. All patients must complete our patient information
form before seeing the doctor. We must obtain a copy of your current valid
insurance card to provide proof of insurance. If you fail to provide us
with the correct insurance information in a timely manner, you may be
responsible for the balance of a claim.
5. CLAIMS SUBMISSION. As a courtesy to you we will submit your
insurance claim. Your insurance company may need you to supply certain
information directly. It is your responsibility to comply with their request.
Please be aware that the balance of your claim is your responsibility
whether or not your insurance company pays your claim. Your insurance
benefit is a contract between you and your insurance company; we are not
party to that contract.
6. NONPAYMENT. If your account is over 90 days past due, you may
receive a letter stating that you have 30 days to pay your account in
full. Please be aware that if a balance remains unpaid, we may refer your
account to a collection agency and you and your immediate family members
may be discharged from our practice.
7. MISSED APPOINTMENTS. OUR POLICY IS TO CHARGE $25.00 FOR MISSED
APPOINTMENTS NOT CANCELED 24 hours prior to appointment time. These charges
will be your responsibility and billed directly to you. Please help us
to serve you better by keeping your regularly scheduled appointment.
Our practice is committed to providing the best treatment to our patients.
Our prices are representative of the usual and customary charges for our
San Jose, California
Phone: (408) 626-7110
Fax: (408) 377-3996