Have questions?

Phone: 301-631-3881
Fax: 301-631-3883

Patient Financial Responsibility Policy

Thank you for choosing the Thomas Johnson Surgery Center as your health care provider.

The Center is committed to providing you quality care. Providing quality care depends on the Center being paid for the services that it provides. This form describes the Center’s Patient Financial Responsibility Policy. You must read and sign this Patient Financial Responsibility Policy before you receive treatment at the Center.

You must pay the Center your co-payment/co-insurance obligation before or on the day of your surgery. The Center accepts cash, checks, and credit cards (Visa, Master Card, Discover, or American Express). You are responsible for paying the balance of the Center’s fee after your surgery, which may be satisfied by either you or your insurance company paying the Center’s fee. The Center charges what is usual and customary for this area. You are responsible for paying the Center’s full charge, even if your insurance company pays a lesser amount based on its arbitrary determination of what constitutes usual and customary rates.

The Center does not have the authority to bill your insurance company unless you provide the Center the correct insurance information and assign your benefits under your insurance plan to the Center (in a separate form). Your insurance policy is a contract between you and your insurance company. The Center is not a party to that contract, and therefore, has no right to require the insurance company to pay it for the services that you receive at the Center.

If your insurance company does not pay your account in full within 90 days of your surgery, or if your insurance company issues a check directly to you to pay the account, the Center will bill you the balance of the account. If you do not pay the balance, the Center has the right to initiate collection proceedings against you. In that case, you will be responsible for not only the balance of your bill, but you will also be responsible for all the fees that the Center incurs in the process of collecting this amount, including collection agent fees, attorney’s fees, and court fees.

Out of Network Patient Explanation:

If we are out of network with your insurance and you have out of network benefits, your insurance company will pay your claim at the out of network rate. We want to support your use of the facility, so we will only be charging you the amount (co-payment, co-insurance) that you would have been responsible for had you used an in-network facility.

Insurance companies will not disclose their out of network payments until the claim is filed and the payment rendered. Because of this, we will base your co-payment and co-insurance on our usual and customary fee. Once the insurance company has paid your claim, we will forward any overpayment to you promptly.

Should you have any questions or concerns, please feel free to contact the business office at 301.631.3881.

Proceed to Anesthesia Consent Form