In this agreement the words “you”, “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payment(s) are credited. The words “we,” “us”, and “our” refer to Pinnacle Family Care, PLLC.

By executing and signing this agreement, you are agreeing to pay for all services that are rendered to you and/or those for whom you are the guarantor via your benefits plan or through direct payment on your behalf to Pinnacle Family Care.

Required Payments: Any co-payments, co-insurance, and/or deductibles are due in full at the time of service. Please note that if you are unable to make your co-payment, deductible, or co-insurance, your insurance carrier may not cover your claim and the unpaid portion of your bill will become patient responsibility, or your appointment will be rescheduled. Because this is an insurance requirement, we cannot bill you for any of the above. For your convenience, we accept VISA, MasterCard, debit, cash, check, and/or money order as forms of payment.

Monthly Statement: If you have a balance on your account, a monthly statement will be sent to you showing the charges on your account and any payment or credits applied to your account. This is your formal notification of any balance that is owed for services rendered.

Insurance Coverage/Cards: It is the responsibility of the patient to notify us of any changes in your insurance coverage. Please provide us with all insurance cards to copy at the time or your visit or at any time there is a change in coverage for you. Pinnacle Family Care cannot be held liable for the misfiling of claims if we do not have your updated information. Pinnacle Family Care is unable to file tertiary insurance at this time.

Due to timely filing regulations, claims will not be refiled with your new or additional insurance carrier if you did not present the insurance card to Pinnacle Family Care, PLLC at the time of service. The patient will be responsible for all balances remaining after insurance payment has been made by your insurance carrier as provided to us on that date of service.

Insurance: As a courtesy to our patients, we will be happy to accept assignment of benefits for most insurance companies. However, please be reminded that insurance is a contract between you and your insurance company. Pinnacle Family Care is not a party to this contract. The patient is fully responsible for all amount(s) not paid or covered by the insurance carrier.

Insurance Disputes: Pinnacle Family Care will not go into dispute with any insurance company with regard to insurance claims regarding any terms of coverage or lack thereof for services rendered. Although the actual dispute process is the patient’s responsibility, Pinnacle Family Care will be more than happy to provide any information requested by your insurance company.

Payments: Unless we approve other arrangements through our Payment Arrangement Plan Contract, the balance due on your monthly statement is due and payable when the statement is issued, and is past due if not paid within thirty days (30). All past due accounts are subject to outside collection at any time.

Demographics: It is the patient’s responsibility to notify our office of a change demographic information for example: a change of address, telephone number or email address. As a courtesy we provide appointment reminders, but if we are unable to contact you by the information provided you are still responsible to make your appointment.

Missed Appointment/No Show Fee: We required advance notice of 24 hours for all appointments for services rendered by Pinnacle Family Care to include specialty service appointments. Appointments can be cancelled at the time of your automated appointment reminder made the evening before your appointment or after hours with our answering service. Otherwise, if after normal business hours, you may contact our after hours service at 910-483-6114, the day before your appointment to cancel. A $50.00 regular follow up and $75.00 for a physical/yearly exam will be accessed to your account for each “no show” appointment or $35.00 for appointments that are cancelled with less than 24-hour notice. This fee or fee(s) must be paid prior to additional appointments being made.

Please note that reminder calls are made as a courtesy and are not required. It is the patient’s responsibility to keep their appointments. Therefore, this fee will not be waived unless under extenuating circumstances.

If a patient misses or has late cancellations for three (3) scheduled appointment, their account will be suspended and the patient will be dismissed/discharged from Pinnacle Family Care, PLLC.

Past Due Accounts: All accounts are to be settled within 15 days of notice Please note that there is a 1.5% interest rate accessed to all past due accounts over 90 days. If your account becomes past due, we are more than willing to assist you in resolving your debt. Our staff will assist you in a payment plan that best suits your budget and will also enable you to satisfy your debt within a set amount of time. After all resources have been exhausted on the part of Pinnacle Family Care, all payment arrangements made according to the Payment Arrangement Plan Contracts that are not adhered to, will be turned over to an outside collection agency for resolution. The patient is responsible for all fees associated with this referral to the outside collection, to include a $30.00 Outside Collection Fee assessed to your account at the time of collections referral. In addition, past due accounts that are turned over to collections, will result in the immediate discharge from Pinnacle Family Care. All account reinstatements will be considered on a case by case basis and the total account payment in full must be made, to include all associated fees via cash, money order, or credit/debit transaction only.

Return Check/Charge Insufficient Funds: Any return check(s) and/or charge(s) against a patient account will result in a $35.00 Insufficient Funds Fee allocated to the patient account and reversal of the original payment. The total amount is due plus the associated fee is due within ten (10) business days of notice. If payment is not made accordingly, the patient’s account will be processed in accordance with the Past Due Accounts policy forestated above. The amount of the returned check must be paid with cash, credit card, or money order only. This fee must be paid prior to additional appointments being made. In addition, future visits will require an alternative form of payment.

All outstanding accounts not paid within the time allotted for NSF Returns, will be discharged from Pinnacle Family Care, PLLC and turned over to an outside collections agency with all associated fees applied as indicated in the Past Due section of this financial policy.

Refunds: Overpayments on accounts will be first credited to any and all outstanding balances that remain unsatisfied. Otherwise, the overage will be applied as a credit to your account. You may use this credit for any services provided by our office.

After Hours Advice: The Pinnacle Family Care office hours are Monday-Thursday 8am-5pm and Friday 8a-1pm.   Our office is also closed during the 12p-1p-lunch hour. Any calls made to our office after business hours will be forwarded to our Emergency Answering Service and a Registered Nurse will handle your call.

Medical Records: All Medical Record requests and fees are handled by our third party vendor, Healthport and are billed in accordance with NC Regulations.

Download the Pinnacle Family Financial Policy Here!