1. We participate with the following insurance carriers: Medicare, Blue Cross/Blue Shield NCA, Blue Shield MD, Capital Care, NYL Care (Health Plus), Optimum Choice, MDIPA, Aetna, MAPSI, PHCS, NCPPO and Alliance as specialists In Cardiology. If an insurance is not listed, please direct questions to our receptionist.

2. It is the RESPONSIBILITY OF THE PATIENT to review his/her insurance coverage and to know if a referral is necessary, pre-certifcation is required or a second opinion is necessary.

3. INSURANCE CLAIMS: We will submit a claim to your insurance carrier, provided we have all the necessary information. We require a copy of your insurance cards (primary and secondary). We will submit claims to secondary carriers after your primary carrier has paid. WE DO THIS AS A COURTESY TO OUR PATIENTS. IT IS UNDERSTOOD THAT IF THE CLAIM IS NOT PAID WITHIN SIXTY(60) DAYS, THE ACCOUNT BECOMES THE RESPONSIBILITY OF THE PATIENT. I The only exceptions are claims to Medicare, BSNCA, BS of MD and Maryland Medical Assistance.

4. PAYMENT AT THE TIME OF SERVICE: If you have insurance, other than a PPO/HMO a co-payment of 20% is due at the time of service. If you do not have coverage, payment in full is due at the time of service. An exception will be made when previous arrangements are made with our business office.

5. HMO/PPO: CO-PAYMENT IS DUE AT THE TIME OF SERVICE. It is the patient's responsibility to obtain the necessary referrals. Only in emergencies will we obtain referrals. If there is no authorization, the visit may be postponed until authorization is obtained, or you may choose to pay, in full, the amount due for the visit. If you have chosen to go outside your plan without a referral, or arrive without a referral, your visit will be billed as such.

6. STATEMENTS: You will receive a statement each month showing charges and credits applied to your account. The printed balance may be different from the balance you owe due to pending insurance. The amount due will be indicated. Aging on the statement is based on the date the service was rendered. It takes between 4 and 8 weeks to receive reimbursement from insurance companies. You are billed on the balance due. Prompt payment is greatly appreciated.

7. PAYMENT ARRANGEMENTS: We are aware that at times medical bills can be overwhelming. We make every effort to work with each patient on an individual basis to assist them In making payment arrangements. Please contact our billing office at 645-5100 or 893-2860 (metro) to discuss your bill. Bills that receive no response after 3 billing cycles will be forwarded to Collections. It will then be necessary to add to your account the fee that is charged by the collecting agency.

Thank you. Should you have any questions about the above policies, please feel free to ask us. We care about you.

I HAVE READ THE ABOVE BILLING POLICIES AND AGREE TO COMPLY.

Signature:____________________ Print Name:____________________ Date:________