Financial Policy

Thank you for choosing Advanced Specialty Anesthesia, LLC for your medical care. We appreciate that you have entrusted us with your anesthesia care and we are committed to providing you with the best patient care possible.

Insurance benefits and coverage options have become increasingly complex. We have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your costs and in answering questions related to submitting your insurance claim for reimbursement.

Anesthesia Cost: Our office estimates the patients out of pocket cost for scheduled surgeries and procedures. Please note this is only an estimate based on the treatment time from your Physician and the benefits verified by your Insurance company. Estimated cost is due prior to the day of surgery for unmet deductibles, co-insurance, co-pays and self-pay charges.

Insurance: We participate in most insurance plans; each plan has different benefits and financial obligations. Not all Insurance policies cover all services. You are responsible for the payment of services rendered regardless of insurance coverage. As a courtesy to our patients, for the plans we participate in, we will submit claims to your insurance carrier for you.

Patient balance and payment arrangements: Balances that are billed to the patient are expected to be paid in full within 60 days of the first statement mailed.

CareCredit: We participate with CareCredit. You may be eligible to participate in short-term financing offers that enable you to make payments over six (6) or twelve (12) months with deferred interest. You are responsible for applying with CareCredit at their website: www.carecredit.com.

Cancellation Policy: If an appointment is not canceled at least five (5) business days in advance you will be charged our no show/cancellation fee of four hundred dollars ($400.00); this will not be covered by your insurance company and is non-refundable or transferrable to a future appointment.

Divorce decrees: This office is not a party to your divorce decree. The responsibility for minors rests with the accompanying adult.

We accept, cash, checks, Visa, Mastercard and CareCredit. A $20.00 fee is assessed for any returned checks. I have read, understand, and agree to the above financial policy.

I understand that charges not covered by my insurance company, as well as applicable co-pays, co-insurance and deductibles are my responsibility.

Patient Name:_________________________ Patient DOB:__________________

_____________________    ____________________________  ________________  ________   Guarantor Name                             Guarantor Signature                                       Guarantor SSN                 Date

1201 Wakarusa Drive Suite A-3 | Lawrence, KS 66049 |
Office: (785) 856-6170 | Fax: (785) 422-5477

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