Financial Policy
Please read this financial policy carefully. If you have any questions about this policy, any member of our staff will be glad to assist you.
The following are the conditions for services provided to the patient by Evolution Health & Wellness.
Payment for Service: Co-pay and deductible amounts are due at the time of the visit. As a courtesy to you, we will file your insurance claims if you provide us with a copy of your current insurance card. We require that you pay your deductible, co-payment, and/or any charges not covered by insurance.
Method of Payment: You may pay your bill with cash, personal check, credit cards, debit cards, or HSA cards.
Returned Checks: A $25.00 service charge will be added on all checks returned for insufficient funds.
Completion of Medical Forms: There may be a $15.00 charge for completion of forms such as disability, physicals, etc. that are not associated with an office visit.
Copies of Medical Records: There may be a charge for completion of this process; (per Texas Administrative Code §165.2. Medical Record Release and Charges).
$.65 per page for the first 30 pages
$.50 per page for all other pages
Clerical fee not to exceed $25.00
*additional postage fees apply
No-show Appointments: A fee of $75.00 for a missed appointment may be charged for all missed appointments not canceled at least 24 hours priors to the appointment time. Patients who miss their initial appointment will not be allowed to reschedule. You will be financially responsible for the fee, as insurance plans do not cover these charges.
You may notify our office of any cancellations by calling during normal office hours.
Payment for Services Provided by Certain Providers: If you are having laboratory and/or diagnostic services by providers other than this office (Quest, Mako, LabCorp, RSFH, MUSC, etc.) you will be billed separately by that service provider.
Collection Policy: Delinquent accounts will be forwarded to a collection agency. We will inform you of your account status on your statement. If you are unable to pay your balance promptly, please call us at (281) 231-8777 to make payment arrangements. We will attempt to contact you by letter before your account is forwarded.
Revision Date: 10/09/2019