CRH Physician Practices, LLC believes that part of good health care practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy.

APPOINTMENT CANCELLATION, RESCHEDULING AND NO-SHOWS Your appointment will be confirmed by our office staff 48 hours prior to your appointment. We do offer a waiting list for patients who would like to be seen sooner than the appointment they were given, and with our patients calling us and cancelling in a timely manner allows us to accommodate other patients should there be such a need. If you do not show for three scheduled appointments, you may be terminated as a patient from the practice.

PAYMENT is expected at the time of your visit. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit.

PAYMENT ARRANGEMENTS If you are unable to pay in full payment arrangements can be made for balances greater than $25.00. Please contact the Business Office at (912) 384-1477 to discuss these terms.

ACCOUNTING PRINCIPALS Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding dates of service.

PROMPT PAY PATIENTS WHO ARE INSURED A 20% prompt pay discount is applied to all full pay payments with balances greater than $50.00 if received within 30 days of the first billing statement. This means anyone willing to/or needing to pay in full at the time of service will receive the 20% discount. All services are expected to be paid in full at the time of service.

SELFPAY PATIENTS A discount is given to patients who have no health insurance and are willing to pay in full on the date services are rendered. This discount applies to all services provided within the office. If patients are not willing to pay in full at the time services are rendered, they will be billed for the full amount charged and payment is expected within 30 days. Please ask our office staff for more information on this selfpay discount.

INSURANCE CRH Physician Practices, LLC will file a claim to the insurance company provided by the patient at the time of service. If the insurance denies a claim to patient responsibility, for any reason, the balance will be forwarded to the patient as their responsibility and appear on their next monthly statement. Payment is due upon receipt of a statement from our office. If our doctors are not listed in your plan’s network, you may be responsible for partial or full payment. If you have questions about your insurance, our Business Office will help you. However, specific coverage issues should be directed to your insurance company member services department (typically, the number is found on the insurance card).

MEDICARE PATIENTS Please make sure you have a full understanding of your Medicare benefits and what might be your responsibility if not covered by Medicare. Your physician wants to diagnose a condition you may have or evaluate how well your treatment is working. To do that, the physician needs to have certain diagnostic tests performed. The physician will tell you what those tests are and why they are necessary. Before your tests are performed, you may be asked to sign an Advanced Beneficiary Notice or “ABN”. Why do we ask you to sign the ABN? We ask patients to sign an ABN whenever Medicare appears likely to deny payment for a specific service.  Please ask our staff for an ABN handout to further explain this process.

MEDICAID PATIENTS Please do not ask to be seen under Medicaid if you have other health insurance. You must be seen under your primary insurance.  You will be asked to sign an insurance waiver stating that you have no other coverage and in the event it is determined that you do and your claim is denied by Medicaid for this reason, you will be responsible for your bill in full.

HIGH DEDUCTIBLE PLAN If you have a High Deductible Plan be prepared to pay for your services in full as you incur them. If surgery is required you will be asked to pay in advance of booking a surgery time.

COORDINATION OF BENEFITS If you are covered by more than one insurance plan, we will gladly file any claims on your behalf. This does not mean that your secondary insurance will pay the remaining balance once the primary insurance processes the claim. Any remaining balance will be your responsibility.

HOSPITAL ADMISSION RELATED BILLS Our fees do not include these services or services rendered by the hospital or other attending physicians during any hospital treatment or surgery.




SURGERY AND OBSTETRICAL FEES – ESTIMATES/FINANCIAL CONTRACTS You will be given an estimate of the fees for these services, based on the physician’s fee schedule, what your deductible, co-insurance is and what percentage your insurance company covers for such services.  You will be expected to pay, in full, for the amount that will not be covered by your insurance.  An initial deposit will be collected from you at your visit in which surgery is scheduled and payment arrangements will be made for the balance upon receipt of your first statement. For our obstetrical patients, you will be required to pay an initial deposit at your first OB visit, and payment arrangements can be made for the remaining balance to be paid in full prior to delivery.  Please note that any ultrasounds, non-routine pregnancy visits, lab work, and hospitalizations (other than for delivery) are not included in the OB package and you will receive a bill for these services.

LABORATORY, RADIOLOGY AND OTHER DIAGNOSTIC SERVICES BILLS Please check with your insurance company to verify what your schedule of benefits allows for any laboratory, x-ray or other diagnostic studies (bone densitometry, mammogram, etc.) that may be ordered by the doctor during your visit.  These services will be billed separately by the laboratory/diagnostic facility that does these tests and are not covered by the payments that you make at this office.  Any insurance claims or problems associated with an off-site laboratory must be dealt with through that facility or their billing agent.  If your insurance company requires use of specific laboratories, please inform the physician and/or staff of this information. 

NON-COVERED SERVICES Not all insurance plans cover all services. In the event your insurance plan determines a service to be “non-covered,” you will be responsible for the complete charge. To find out what your insurance plan covers or what your financial obligation may be, we suggest that you call the member services department of your insurance company (the phone numbers are on your insurance card). All procedures billed in this office are considered covered unless limited by your specific insurance policy.

ADDITIONAL TESTING For preventative care exams the physician may request you to undergo certain additional screening tests. Please contact your insurance company to determine if these are covered benefits to avoid incurring charges for which you will be held responsible.

·       Newborn-12 years: Vision & hearing screening, developmental/behavioral assessments, immunizations, and screening lab work (newborn metabolic/hemoglobin screening, hematocrit or hemoglobin, lead screening, tuberculin test, dyslipidemia screening, STI screening, cervical dysplasia screening)

·       13-18 years: Pap testing, screening lab work (CBC, CHEM, TSH, CRP), gonorrhea, Chlamydia screening, mental health benefits (libido issues, depression, anxiety – these are considered ‘Mental Health Issues by Insurance Companies and may not be covered if you do not have ‘Mental Health’ Benefits)

·       19-39 years: screening lab work (CBC, CHEM, TSH, CRP), gonorrhea, Chlamydia screening, baseline mammogram at age 35, mental health benefits, mental health benefits (libido issues, depression, anxiety)

·       40-64 years: yearly mammograms, bone densitometry, colonoscopy referral after age 50, screening lab work (CBC, CHEM, TSH, CRP), mental health benefits (libido issues, depression, anxiety)

·       65 & above: yearly mammograms, bone densitometry, screening lab work (CBC, CHEM, TSH, and CRP), mental health benefits (libido issues, depression, and anxiety), and Pap smear every 2 years unless risk factors exist.  Please instruct your physician if you wish to have the pap completed yearly at your expense.

PAST DUE ACCOUNTS  Any patient with a past due account may be denied a future appointment until balance is paid or a payment arrangement is made. You may contact our Business Office to set up a payment plan.

COLLECTION AGENCY AND BAD DEBT We will not schedule any type of appointment for you if your account has been turned over to collections or if you account has a bad debt write-off. You must pay any amounts due either with CRH Physician Practices, LLC or our outside collection agency prior to booking any type of follow-up appointment.

BILLING ERRORS Inadvertent billing errors may occur; we do our best to correct problems as quickly as they are brought to our attention. If you feel there is a billing error on your account, please contact our Business Office at (912) 384-1477.

REFERRALS It is your responsibility to bring any required referral for treatment at or prior to your visit. If you do not have your referral, your visit may be rescheduled or you may be financially responsible for the services provided.

THIRD PARTY INSURANCE AND MOTOR VEHICLE ACCIDENTS CRH Physician Practices, LLC will occasionally accept patients who have been injured in a motor vehicle accident or other liability injury; however the decision is up to the provider whether or not to see an injured patient. There is no guarantee for payment even if the injury is covered under a first-party payer or has approved sponsorship from Advance Medical Funding. CRH Physician Practices, LLC has the right to be reimbursed for any medical benefits from the proceeds of any personal injury policy (PIP), Medpay, uninsured or underinsured motorist coverage, or workers compensation coverage’s applicable to this incident.

ADDITIONAL CHARGES There is a charge for checks returned for “Not Sufficient Funds.” These checks will go to Payliance and will need to be handled with them.

FORMS FEES Completing insurance forms, copying medical records, etc. requires office staff time and time away from patient care for our doctors. We require pre-payment for completing forms, copying medical records, notarizing, or for extra written communication by the doctor. The charge is determined by the complexity of the form, letter, or communication. Base form charges are $15 per occurrence and must be picked up by the patient. Copying fees for medical records is based off of the State guidelines. CRH Physician Practices, LLC will have 15 business days in which to copy records before making them available for patient to pick up, and these 15 days will commence after payment for copying has been received and after patient has signed this form authorizing records’ release.

ASSIGNMENT OF INSURANCE BENEFITS I hereby assign, transfer, and set over directly to CRH Physician Practices, LLC sufficient monies and/or benefits for basic and major medical to which I may be entitled for professional and medical care, to cover the costs of the care and treatment rendered to myself or my dependent in said clinic. I authorize CRH Physician Practices, LLC to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to CRH Physician Practices, LLC. I authorize CRH Physician Practices, LLC to release all medical information (including, but not limited to, information on psychiatric conditions, sickle cell anemia, alcohol and drug abuse, and HIV or communicable diseases) requested by my health insurance carrier, Medicare, other physicians or providers, and any other third-party payers.

RELEASE OF INFORMATION I hereby authorize and direct CRH Physician Practices, LLC to release to governmental agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment.

STATEMENTS A statement will be sent to the patient once a balance becomes patient responsibility and will continue every 30 days thereafter. If payment is not received the account will go through our internal collection process initially and then may be referred to an outside collection agency.

MINOR PATIENTS For all services rendered to minor patients, we will look to the accompanying adult or custodial parent or guardian, for payment.  We will not disclose any confidential information to the parent or guardian without written authorization from the minor.







Insurance Coverage Waiver

(Waiver 1 is to be initialed by patients who have no insurance coverage available at the time of service. Waiver 2 is to be initialed by patients who have Medicaid and no other insurance carrier. Waiver 3 is to be initialed by patients who have insurance (Commercial, Medicare or Medicaid). Waiver 4 is to be initialed by patients who are not covered by Medicaid, Wellcare, Peachstate, Amerigroup or any other government funded healthcare plan- It is possible for patients to have to initial more than one waiver)



1.)   I, _________________________________________ with a date of birth _______________, understand that my eligibility for

coverage by ______________________________________ (name of insurance company) cannot be confirmed at this time.  I wish

to receive medical service from CRH Physician Practices.  If it is determined that I am not eligible for coverage, I understand that I

will be responsible for payment of all services provided.


Patient Initials: ________

2.)  I, _________________________________________ with a date of birth _______________, confirm that I have no other  healthcare coverage/insurance except for Medicaid (including Wellcare, Peachstate and Amerigroup).  I understand that if Medicaid denies my claim for other insurance coverage that I will be responsible for payment of all services provided.

Patient Initials: ________

3.) I, _______________________________________ with a date of birth ________________, understand that it is my responsibility to understand my insurance benefits. I understand that if my insurance carrier denies my claim for non-covered or maximum benefits exceeded then I will receive a bill for those services.

Patient Initials: _______

4.) I, _______________________________________ with a date of birth ________________, confirm that I am not covered by Medicaid, Wellcare, Peachstate, Amerigroup or any other government funded insurance plans at the time of my visit.  I will notify the office staff prior to my being seen by the provider if I have or plan on applying for one of these plans.  I understand that if I do not notify the office of coverage by one of these plans within three months of my visit, then the office will not file a claim on my behalf and I will be responsible for the balance in full.

Patient Initials: _______

5.) I, ______________________________________ with a date of birth _________________, understand that CRH Physician Practices is not in network with my insurance plan __________________________. I understand that I will be responsible for upfront payment of any services rendered and that CRH Physician Practices will not file a claim to my insurance carrier.  If other services are rendered during my visit and are not paid in full at the time of service, I understand that I will receive a bill for those services and prompt payment is expected.


Patient Initials: ________


These policies are subject to change without notice. I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.


Signature of Patient (or Guarantor, if applicable)                                                                                                                        Date


Patient Name (Please Print)