Thank you for choosing Sun Radiology for medical services. The medical services you seek imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for the services you receive. To assist in understanding that financial responsibility, we ask that you read and sign this form. Feel free to ask if you have any questions regarding your financial responsibility. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for your expenses or carries your insurance, please share this policy with them, as it explains our practices regarding insurance billing, copayments, and patient billing. By signing below and/or by receiving medical services from Sun Radiology, you agree:

  1. You acknowledge and agree to the financial policies of Sun Radiology.
  2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by your insurance carrier , which are not otherwise covered by supplemental insurance.
  3. You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply: (a) your health plan requires prior authorization before receiving services at Sun Radiology, and you have not obtained such an authorization or referral; (b) you receive services in excess of such authorization or referral; (c) your health plan determines that the services you received are not medically necessary and/or not covered by your insurance plan; (d) your health plan coverage has lapsed or expired at the time you receive services ; or (e) you have chosen not to use your health plan coverage. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly.
  4. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of current insurance and paying any co-pays or other patient responsibility amount at each visit. Your insurance card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file, or are unable to verify your eligibility for benefits, you will be treated as a self-pay patient. As a self-pay patient, our fee is expected to be paid in full at the time of service. If the insurance card or other necessary information is provided after the visit, we may file a claim with your insurance; and, if paid in full by your insurance, you will be reimbursed.
  5. We may verify your insurance benefits or submit your claim to your insurance carrier as a courtesy to you. Without waiving any obligation to pay, you assign to Sun Radiology, for application onto your bill for services, all of your rights and claims for the medical benefits to which you, or your dependents are entitled, under any federal or state healthcare plan (including, but not limited to, Medicare or Medicaid), Insurance policy, any managed care arrangement or other similar third-party payor arrangement that covers health care costs and for which payment may be available to cover the cost of the services provided to you. You authorize Sun Radiology and associated physicians and staff to release patient information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, radiology imaging results or other documents related to your treatment that is deemed necessary to process this claim to the necessary insurance companies, third party payors, and/or other physicians or health care entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance coverage. Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim. Sun Radiology does not accept responsibility for incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans.
  6. If your insurance carrier does not remit timely payment on your claim, you will be responsible for payment of the charges within the terms set forth herein. Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance carrier. If any payment is made directly to you for services billed by us, you agree to promptly submit same to Sun Radiology until your patient account is paid in full. If you make a payment that results in a surplus on your account, you authorize Sun Radiology to apply the overpayment to your other date of services for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a Financial Responsibility Party.
  7. Whether or not you have insurance or are self-pay, payment of any account balance is due at our Patients Account Offices in Peoria, AZ within thirty (30) days of receipt of your billing statement. If any balance on your account is over ninety (90) days past due, your account will be in default and may be referred to a collection agency. For small balances, less than $10.00, we may stop sending billing statements any time after the initial statement, but you understand that the amount shall remain due and owing until paid in full. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about your account, insurance coverage or our financial policy, please do not hesitate to ask us. We are here to help you.
  8. We accept payment by check, cash, money order, debit cards, or credit cards (Visa, Master Card,) and Care Credit.
    1. Payment by Check:
      If payment is made by check and it is returned or declined for any reason, your account will be charged a surcharged of $35.00 or up to the applicable state maximum legal limits, whichever is lower, in addition to any costs assessed or charged by any depository institution.
    2. Payment by Credit Card/Credit Card on File:
      When you pay by credit card to be held on file, you agree to keep the credit card information current, and you authorize Sun Radiology to securely store your credit card information, and only charge it should you have an outstanding balance or any leftover balance from a processed claim in the future. The storage system used is fully compliant to the highest level of credit card storage security regulations. Once stored, only the last four (4) digits of your credit card are viewable by Sun Radiology personnel. If the patient responsibility portion of your charges (including charges applied to your deductible and/or coinsurance) is not paid in full within thirty (30) days following receipt of the financial responsibility statement, then Sun Radiology will bill your stored credit card for the outstanding balance due.
  9. Managed Care (HOM, PPO, etc.):
    All managed care co-payment amounts are due at the time of service. If your insurance plan requires a prior authorization for imaging services you are responsible that your exam/services has been authorized by your insurance before the exam/services are performed. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for a larger amount or all of the charges. You acknowledge that it is your responsibility to be aware of what services are covered and you agree to pay for any service deemed to be non- covered or not authorized by the plan.
  10. Medicare:
    Sun Radiology is a participating provider with the Medicare program and accepts as payments the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment is covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information
  11. Medicaid:
    If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the full/entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You will be solely responsible for all non-covered procedures. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.
  12. Non-payment on Account:
    Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that Sun Radiology has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record.
  13. Authorization to Contact:
    You authorize Sun Radiology personnel to communicate by mail, voicemail, text messages, and/or e-mail according to the information provided in your patient registration information. Sun Radiology or any agent or servicer of your patient account, may use any information you have provided, including contract information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection.


By signing below, each of the undersigned acknowledges that: (a) I have been provided a copy of the Sun Radiology patient financial responsibility statement ; (b) I have read, understand, and agree to their provisions and agree to the specified terms; (c) I agree to pay all charges due (or to become due) to Sun Radiology for the below Patient’s care and treatment, including co-payments and deductibles, as required or provided pursuant to my insurance plan and/or the insurance plan of another, as applicable; (d) benefits, if any, paid by a third-party will be credited on the Patient account; (e) regardless of my insurance status or absence of insurance coverage, I am ultimately responsible for the balance on the account for any services rendered; (f) if I failed to make any of the payment for which I am responsible in a timely manner, I will be responsible for all costs of collecting the money owed, including collection agency fees, and (g) failure to pay when due may subject me to late payment charges and can adversely affect my credit report.
I further agree that a photocopy of this Patient Responsibility Financial Statement shall be as valid as the original.

This agreement is effective for one year from the date signed.