Collection of Payment Information at Time of Service

As a requirement for ALL PATIENTS, Glow Midwifery & Wellness requires a credit/debit card to be securely kept on file for all patients, even if your upfront financial responsibility at the time of your visit is determined to be $0. You will be notified in a reasonable timeframe with a statement of your total financial responsibility after insurance processing. If statement balances are not paid within 15 days of your first statement, KC Full Circle Midwifery & Family Wellness will process your card for the balance due. Your signature below authorizes these charges to be paid with your card on file. 

Estimation of Fees

The estimation of fees for your visit is based on typical care needs for the main reason for your visit. However, remaining balances will be determined once your visit is completed, and any amount owed will be due at the time of the visit and may be billed. We strive as a clinic to make patients aware of any additional charges or services rendered during the visit.

Self-Pay

We do not participate in any insurance plans, and therefore, the full payment of the estimated service charges is due at the time of service. In some cases, point of care testing such as a lab draw, urinalysis, or other ancillary service, may be billed following your visit. You will be notified in a reasonable timeframe with a statement of your total financial responsibility after coding and billing is completed within our clinic.

Superbill

We understand you want to get the most out of your health insurance plan. We encourage you to familiarize yourself with your insurance plan's requirements before seeking care from an out-of-network provider. We can provide you with a Superbill after your visit, which you can submit to your insurance company for reimbursement. We do not provide any billing services directly to insurance companies.

Appointment No-Shows

If you anticipate that you may be unable to make a scheduled appointment, please notify our office at least 24 hours in advance, so that another patient in need of an appointment might be seen. Failure to notify us will result in a $50 no show fee. Please note: If you fail to show up for a scheduled appointment three consecutive times, you may not be permitted to reschedule

FMLA Paperwork

Glow Midwifery will complete ONE FMLA form per calendar year for a patient free of charge. Each additional FMLA form in a calendar year will be subject to a $25 service charge.

Credit Card Authorization Fees

If you are using a credit/debit card, a 3% transaction fee is applied to your total. This fee is applied to each payment made using a credit card/debit card and is added to your total at the end of your visit.