CARDIOVASCULAR CONSULTANTS MEDICAL GROUP
Consultative and Interventional Cardiology
Cardiac Electrophysiology
Peripheral Vascular Disease
Ara G. Tilkian, M.D., F.A.C.C. A Partnership of Medical Corporations Isaac Wiener, M.D., F.A.C.C.
John S. Tsakonas, M.D., F.A.C.C. Kenneth K. Tam, M.D., F.A.C.C. M. Ganesa Pandian, M.D., F.A.C.C. Ting S. Yee, M.D., F.A.C.C. Leo Kassabian, M.D., F.A.C.C. Adel K. El-Bialy, M.D., F.A.C.C. Shahe Garabedian, M.D., MS, F.A.C.C. Jayanta R. Das, M.D. Prasanna K. Challa, M.D. Ashish K. Aggarwal, M.D. Abhishek Sinha, M.D., F.A.C.C.
Our Financial Policy
We are dedicated to providing the best possible care for you, and we want you to completely understand and agree to our financial policy.
Appointment No-Show/Cancellation: If you cannot keep your scheduled appointment, please call our office within 24 hours of your appointment date/time. Failure to give 24 hour cancellation notice or failure to show up for your appointment, will result in a charge of $25.00. Failure to give 24 hour cancellation notice or failure to show up for your Nuclear test appointment, will result in a charge of $145.20 for the wasted radionuclide that we cannot use on other patients.
Office Visit Copayment: If your insurance plan requires an office visit copayment, this will be collected at the time of service. It is a requirement placed on us by your insurance plan.
Deductible: If your insurance plan has a deductible that has not been met prior to your services being rendered, you will be asked to pre-pay a portion of the known medical expenses at the time of service.
Previous and/or Past Due Balance: If there is any Self Pay balance due from previous dates of service, you will be required to pay that at time of service.
Medicare Patients: You are personally responsible for your Part B Deductible and 20% coinsurance. As a courtesy, we will bill any supplemental insurance, but you ultimately will be responsible for any deductible and coinsurance applied by Medicare and/or the Supplemental Plan. You may also be asked to sign an ABN (Advanced Beneficiary Notice) for services known not medically necessary by Medicare.
Forms: There is a $25.00/per page fee for any/all form(s) completion.
Medical Records Request: There is a $35.00 fee for a medical records request. Payment for these records will be collected prior to records being released.
Returned Check Fee: There is a $25.00 fee that will be charged to your account with us for any returned check. If we receive 2 returned checks, only cash or credit card will be accepted for any/all future payments.
Acknowledgement and Agreement of Our Financial Policy
I have read and understand the handout, Our Financial Policy.
I hereby authorize insurance payment directly to Cardiovascular Consultants Medical Groupfor services rendered. I understand that I am financially responsible for all copayments, deductibles, coinsurance, and non- covered services. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, obtain authorization for medical services and communicate with other treating Physicians.
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Patient Name/MRNDate
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Signature of Insured/Authorized Person
16542 Ventura Boulevard, Suite 402, Encino, California 91436 Phone (818) 782-5041 Fax (818) 205-9091
14901 Rinaldi Street, Suite 110, Mission Hills, California 91345 Phone (818) 365-1339 Fax (818) 898-4301
100 UCLA Medical Plaza, Suite 410, Los Angeles, California 90024 Phone (310) 824-3378 Fax (310) 208-2870
23929 McBean Parkway, Suite 216, Valencia, California 91355 Phone (661) 259-1534 Fax (661) 284-3670