Mountain Valley Medical Clinic

Billing questions: Tel # 800.733.0250

Mountain Valley Medical Clinic Financial Policy

Thank you for choosing our medical clinic! We are committed to providing you with the highest quality healthcare. Please understand that payment of your bill is part of this treatment and care and we appreciate attention to our payment terms.

All patients must complete our Patient Registration Form. We believe that a good relationship is based on understanding and open communications. Our staff has been instructed to make every effort available to you to clarify any misunderstanding you have concerning your balance. Please ask.

For your convenience, we have answered a variety of commonly-asked financial policy questions below. If you need further information about any of these policies, please ask to speak with a member of our front desk team or our billing service, Mid Vermont Medical Billing at 1-877-773-0250.

How May I Pay?

We accept payment by cash, check, VISA, and Mastercard at our reception area at the time of visit for co-pays and for payment in full.

Payment responsibility:

Non-established MVMC patients are expected to make payment in full at the time of visit. We will provide you with a detailed receipt for you to submit to your insurance for reimbursement.

Established MVMC patient are expected to make payment in full upon receipt of a bill showing your balance due ?or according to the terms agreed to with the billing service. Failure to respond to billing requests and/or adhere to agreed upon payment plans will automatically result in your account sent to collections.

Sliding Fee Program:

A sliding fee schedule is available to community members living in our  catchment area who are uninsured and/or unable to pay the full cost of their medical care. Sliding fee applications are available upon patient request at the front desk along with instructions and qualifying information. MVMC sliding fee program is limited to services provided at MVMC. It is not transferable with any other medical facility, reference lab, or pharmacy.

When is my account delinquent?

An account is considered past due 30 days following billing unless other arrangements have been made. It is the patient's responsibility to respond to the billing service with any billing inquiries. Unpaid accounts beyond 90 days are considered delinquent and will be forwarded to our collection agency. There is a 15% collection fee premium added to all outstanding accounts after 90days. Once in collections the account status is non-reversible.

Nonpayment of Co-pay?

MVMC is obligated to collect all co-pays at the time visit by contracted insurance carriers. A $10 late fee will be billed directly to the patient should co-payment not be collected at the time of visit. This fee is non-reversible.

What Is My Financial Responsibility for Services?

MVMC accepts assignment for Medicare, Medicaid of VT, BC/BS of VT, CBA, Cigna, GreatWest Life, MVP, New England Financial, Secure Horizon, Tricare, and Workers Comp. As a courtesy, MVMC will bill your insurance company on your behalf. Patients are ultimately responsible for any unpaid claims as well as knowing the details of their insurance plan including co-pay amounts.  

What about missed appointments?

It is the patients responsibility to call ASAP if you are unable to keep an appointment. Please notify our office at least twenty-four(24) hours prior to the appointment time when possible. No shows are both costly and take away precious patient care time from other patients seeking medical care. Three (3) non cancelled missed appointments in a twelve month period is grounds for patient termination from the practice.

Copying fees:

As a one time courtesy, MVMC will copy your MVMC records only, free of charge. Additional requests for all or part of MVMC record copying will result in a minimum of $10 processing fee or $0.50 per page which ever is greater and will be billed directly to the patient unless other arrangements are mutually agreed upon prior to copying.


Collections:

Any patient sent to collections will be responsible for all collection fees. There is a 15% premium charge for all balances in collections. Once in collections, MVMC has little ability to assist with patient accounts. Patients with questions are encouraged to call the billing service upon receiving their bill. Do not wait until 90days has elapsed to respond to your bill.

What if My Child Needs to See the Physician?

A parent or legal guardian must accompany patients who are minors on the patient's first visit. This accompanying adult ?(who consents to the treatment) is responsible for payment of the account. We will not be involved in separation/divorce disputes.


A copy of this policy may be made available to you by a receptionist ?and is located on our website at www.ourclinic.org.

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-payments and deductibles, are my responsibility.  I authorize my insurance benefits be paid directly to Mountain Valley Medical Clinic (MVMC).  I authorize MVMC to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.
Printed Legal Name:_____________________________

Signature: _________________________________    Date:______________