Financial Policy Form

This form was created to help our patients understand what is expected of them regarding financial arrangements for medical care. If you have any questions regarding these policies, please feel free to ask.

1. WITHOUT EXCEPTION, any charges for any medical services that are not covered by insurance are the full responsibility of the patient, or the responsible party who has signed for the patient.

2. Patients are expected to pay for their office visits at the time of service. Patients who are covered by  Medicare or any managed care with which Dr. Kirkland N. Lozada participates, will be responsible for the  copayment at the time of service. Patients needing a referral for their visits are responsible for  obtaining those referrals.

3. Insurance claims will be submitted by this office. The charges submitted to the insurance carrier will  become due and payable ninety days (90) from the date of service. In the event of duplicate payment of a service, refunds will be made in a timely manner.

4. Dr. Kirkland N. Lozada is a participating provider with Medicare. We accept assignment on all services covered by Medicare. This means we accept Medicare’s allowed amount. You, the patient, are responsible for all deductible and coinsurance amounts. By law the physician is not allowed to write off the deductible or coinsurance. If you have a second carrier, and want us to submit that portion to them, you must provide a copy of the insurance card (front and back).

5. The responsibility for payment of services rendered to any dependent  child, whose parents are divorced, rest with the parent who seeks treatment. Any court ordered responsibility judgment must be determined between the individuals involved without the inclusion of the office. 

6. Patients with no insurance coverage, or involved in an accident where another party is liable, are asked to pay as services are rendered unless financial arrangements have been made in advance. 

7. Patient agrees and acknowledges that he / she is responsible for all attorney fees and costs incurred by Penn Medicine, Dr. Kirkland N. Lozada should any type of legal action be required to collect any unpaid balance owed by the patient and / or the retention of an attorney by Dr. Kirkland N. Lozada is  required.