Financial Policy
FCDI Financial Policy
Release of Information/Financial Policy
Thank you for choosing Forest City Diagnostic Imaging Center, LLC as your health care provider. The following is a statement of our Release of Information. Financial Policy, which we require you to read and sign prior to any treatment. All patients must also complete and sign our Patient Registration Form.
Release of Information/Medical Records
By signing this form, you authorize Forest City Diagnostic Imaging Center, LLC or its designee(s) to release and disclose such medical records, information and documentation as may be necessary or appropriate in order to process insurance claims and to obtain payment on your behalf. You also authorize the release of information acquired in the course of your examination or treatment and all information pertaining to your history and progress in your case. This includes any alcohol or drug abuse data that may be protected by Federal Regualtions-42CFR Part 2. You agree that a photocopy of your original authorization shall be considered equally authentic.
Regarding Insurance
We cannot bill your insurance company unless you provide us with your insurance information and any special claim forms required by your insurance company. We accept assignment of insurance benefits. That means your insurance will pay us directly the amount due based upon your benefit coverage. By signing this form, you authorize assignment of you benefits to Forest City Diagnostic Imaging Center, LLC for treatment and related services. However, we do require, as your insurance benefits require, payment of co-pays, co-insurance and deductibles at the time of service. Your insurance policy is a contract between you and your insurance company. Please know your benefits. Please be aware that only your insurance company can tell you if the services provided are covered under your benefit plan.
While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. In the event that your account is turned over to an outside collection agency, you will be responsible for an additional 30% of the balance owed and/or all the attorney fees and costs incurred to collect the unpaid debt. Those Insurance plans that we are a Participating Provider
All co-pays and deductibles are due at the time of treatment. Prior to seeking payment form you, we will work with these plans to obtain payment. In the event that your insurance coverage changes to a plan in which we are not a participating provider, refer to the paragraph below. You may contact our office at any time to obtain a list of plans that we participate in.
Those Insurance Plans in which we are NOT a Participating Provider. If your insurance company has not paid your account in full within 45 days of the billed date, the balance is your responsibility. Your assistance in collection from your insurance company may be required.
WE ACCEPT PAYMENT IN THE FORM OF CASH, PERSONAL CHECK, VISA OR MASTERCARD
While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. In the event that your account is turned over to an outside collection agency, you will be responsible for an additional 30% of the balance owed and/or all the attorney fees and costs incurred to collect the unpaid debt. Those Insurance plans that we are a Participating Provider:
All co-pays and deductibles are due at the time of treatment. Prior to seeking payment from you, we will work with these plans to obtain payment. In the event that your insurance coverage changes to a plan in which we are not a participating provider, refer to the paragraph below. You may contact our office at any time to obtain a list of plans that we participate in.
Those Insurance Plans in which we are NOT a Participating Provider: If your insurance company has not paid your account in full within 45 days of the billed date, the balance is your responsibility. Your assistance in collection from your insurance company may be required.
WE ACCEPT PAYMENT IN THE FORM OF CASH, PERSONAL CHECK, VISA, MASTERCARD AND DISCOVER.
Usual and customary rates
Our practice is committed to providing the best treatment for our patients. We charge what is usual and customary for our area. The federal government agency that administers the Medicare and Medicaid programs, has determined that except for certain circumstances, the discounting or waiving of a patient’s co-pay or deductible is unlawful. Additionally, under the new HIPAA regulations, we are now not allowed to discount or waive patient’s co-pays or deductibles as outlined by benefit plans offered by other third-party payers. You are responsible for payment unless we are a participating provider for your insurance company.
Patient Balances
Patients are responsible for full payment at the time of service if not covered by some other third party such as Medicare, Medicaid or private insurance.
Refunds
If you or any third-party payer is due a refund after all payments have been received, we will issue refunds on a quarterly basis unless a specific request is made.
Cases Involving An Attorney
If you are receiving services for an auto accident, worker’s compensation case or personal injury and you are working with an attorney, we expect a minimum monthly payment of $25 in order to continue treatment. We also require information relating to your group health coverage. Both your group health and the appropriate auto/worker’s compensation carrier will be billed at the same time. This procedure is necessary in order to have a claim on file with the group health in case the auto/worker’s compensation carrier does not pay or is exhausted at some point during your treatment. This procedure not only protects Forest City Diagnostic Imaging Center, LLC but you as the patient.
Health Insurance Portability and accountability act of 1996 (hipaa)
HIPAA is a protective measure safeguarding patient privacy and confidentiality. By signing this Agreement, I acknowledge that I have received information pertaining to my rights as covered under the Health Insurance and Portability and Accountability Act of 1996.
No Surprises Act of 2025
In accordance with the No Surprises Act, we are committed to providing high quality diagnostic imaging at an affordable price. We can provide you with your out of pocket expenses before you have your scan. Please call our Billing Dept at 708-675-1500. For more information please visit: