NO ONE WITH INSURANCE HAS TO PREPAY FOR SERVICES 

Prior to treatment, everyone must provide payment authorization by credit card, electronic bank account debit or deposit to cover all unknown Patient Responsible balances. 

(Medicare beneficiaries & authorized workers compensation excepted.) 

We accept Master Card, Visa, American Express, & Discover 

• Patients will be required to authorize payment by credit card or bank draft for services received prior to seeing the provider.  
• This document authorizes DDMOC to automatically bill your credit card or bank account, for any balances due by patient.
• The policy applies to surgical fees and office visits.

If we are contracted providers for your insurance plan: 

1. You are required to pay your regular co-payment at the time of your visit
2. We will file an insurance claim for your treatment.
3. You will receive an Explanation of Benefits from your insurance company
• Reflecting the balance you owe when payment is made to our office.
• Kansas and Missouri law require insurance to make payment in 45 days
• You may choose to pay this amount when the EOB is received
4. You will receive a statement from us, notifying you of your balance.
• You may contact us immediately upon receipt of the statement to make other payment arrangements
• We will then use the authorization to automatically charge your credit card or bank account for the amount you owe.
5. For large balances, you may make arrangements for regular monthly automatic payments from your credit card or bank account.

For non-participating plans (Plans not contracted with Dickson-Diveley): 

1. You will be offered a cash discount for payment in full at the time of the visit.
2. If the cash discount is given, we will not file a claim with your insurance, but provide you a copy of the superbill.
3. Patient’s with non-participating insurance plans, that do not choose the cash discount, will be required to use the prepayment authorization for each visit.

Motor Vehicle Accidents: 

1. Patient’s seeking non-emergency treatment from a Motor Vehicle Accident or Third Party Liability case, will be required to provide the prepayment authorization for each visit.
2. Motor Vehicle Accident and Third Party Liability patients will also be required to pay $200 pre-payment prior to the first visit.

Workers Compensation and IME 

Patients with authorized workmen’s compensation or scheduled for prepaid Independent Medical Opinion will not be subject to this Financial Policy.