Thank you for choosing Main Street Family Practice as your primary care provider. We are committed to providing you with quality healthcare. Because some of our patients have had questions regarding patient and insurance responsibilities for service rendered, we wanted to make our expectations of your financial obligations clear to you.

Please read it fully, ask any questions you may have, and sign in the space provided on the second page. A copy can be provided to you upon you request.

****Understanding your health insurance coverage is your responsibility****

We participate in most insurance plans, including Medicare.

It is your responsibility to check with your insurance company to make sure Main Street Family Practice is contracted with them and that you are eligible to be a patient here under that health plan.

If you are insured by a plan in which we DO NOT have a contract, payment in full is expected at each visit at our self-pay rates.

If you are insured by a plan in which WE DO have a contract, but you are unable to provide us with up-to-date insurance information, or your insurance carrier is stating you were not eligible for services, payment in full for each visit is required. Main Street Family Practice is required by contract to bill the patients based on what the insurance company determines is the patient’s responsibility.

If you are unsure of what is or is not covered by insurance, we advise you to contact your insurance company prior to receiving any services at the practice.


*****All co-pays must be paid at the time of service! ****

If your co-pay is not paid at the time of service, or within 7days, a $20.00 processing fee will be added to your account. Failure to collect co-payments and balances at the time of service could be considered a violation of our contract with your insurance company.


Please be aware that some and perhaps all of the services you receive may be be non-covered, not considered reasonable or necessary by Medicare or other insurers. You would still be financially responsible for these patient requested and provided services.


****It is your responsibility to provide us with a current valid insurance card and a signed copy of this payment policy. ****

If at the time of the visit your insurance company is not listing you as an active, eligible patient you will be considered an uninsured patient and our self- pay rates will apply. Failure to provide us with your current eligible insurance information, prior to services will result in your responsibility to contact your carrier if you believe it is an error on their end.

Claim Submission

We will submit your claims and assist you in any way we can to help get claim paid. Your insurance company may need you to supply them certain information directly. Your insurance plain is a contract between you and your insurance company, Main Street Family Practice is not part of that contract.

New Payment Options

We have partnered with Swerve Pay, an online payment company, which will allow you to make payments to Main Street Family Practice conveniently via smartphone or online and receive receipts automatically in the same way. The practice will continue to accept payments via cash, check or charge. We will also continue to accept payments via phone, mail and in person. Although we do encourage patients to give our digital payment system a try. For more details, please inquire with staff.

By supplying my home number, mobile number, email address, or any other personal contact information, I authorize my health care provider to employ a third- party automated outreach and messaging system to use my personal information, the name of my care provider and other limited information. For purpose of notifying me of an un- paid balance. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information regarding healthcare events, unpaid balances and to leave a reminder message on my mobile phone, email, and voicemail or answering system.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

I have read and understand Main Street Family Practice’s financial policy and agree to abide by its guidelines. Please Sign Below (today's date and time will be captured on submit).

I acknowledge reading the MSFP Payment Policy. A date and time stamp, along with your acknowledgement will be recorded. You will receive a copy of this submission via the email address you listed.

I Acknowledge