Financial Policies and Patient Forms

Please download, complete, and bring the following forms with you to your first appointment:

New Adult Patient Information Form
New Minor Patient Information Form
SSMC Billing Policy

As a courtesy to you, our patient, we will be happy to accept assignment of benefits for most insurance companies. However, it must be understood that the contract is between the patient and the insurance company. The patient is fully responsible for any amount not paid by the insurance carrier. Our office policy regarding insurance claims is as follows:

  • It is the patient’s responsibility to provide our office with complete insurance or billing information at the time of service, or the fees must be paid in full.
  • The patient is required to pay their portion at the time of service. This includes co-pay amounts, deductibles, coinsurance, or non covered services.
  • Our office cannot guarantee the amount that an insurance company will pay. Any unpaid balances after 90 days from the date of service will be the patient’s responsibility to pay. It is the patient’s responsibility to be familiar with his or her insurance coverage.
  • Our office will not go into a dispute with any insurance company over a claim. This is the patient’s responsibility and obligation. We will provide any information requested by the insurance company.
  • A charge of $35.00 will be assessed for any returned checks. The patient/guarantor will be held responsible for any collection charges incurred on a delinquent account.

Southside Medical Care Centers accept numerous insurances most major credit cards, and checks. We look forward to providing you with the best medical care!
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