Peninsula Gastroenterology Medical Group, Gastroenterologists logo for print
Redwood City: 2900 Whipple Ave | Suite 245 |Redwood City, CA 94062 • Phone: 650-365-3700
Mountain View: 2500 Hospital Drive | Building 8, Suite B | Mountain View, CA 94040 • Phone: 650-964-3636

Peninsula Gastroenterology Medical Group, Gastroenterologists

650-365-3700Redwood City
650-964-3636Mountain View

Patient Financial Policy Form


Thank you for choosing Peninsula GI Medical Group as your health care provider. We are committed to providing you the best possible medical care. Please understand that payment of your bill is important. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.

Medical doctors are licensed and regulated by the Medical Board of California
(800) 633-2322

**All Patients must complete a Patient Information Form before seeing the doctor.

Regarding Insurance:
As a courtesy our office will bill your insurance for the services you will receive. We cannot bill your insurance company unless you give us correct insurance information. It is your responsibility to inform us if your insurance has changed at any time during treatment. Please understand that your bill is ultimately your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 business days, it will then become your responsibility to pay the balance. We accept Cash, Check and all major credit cards. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your medical insurance.

**All co-pays are due at the time of treatment.

***We DO NOT accept any Blue Cross Covered California Plans or Medi-Cal plans. If you have Blue Cross, it is your responsibility to know if it is through Covered California. If this is realized after your visit, you will be responsible for the entire cost of the visit.

Missed Appointments:
Due to the amount of time allotted for scheduled endoscopic procedures, we do request at least 3 working days notice for cancellation of any procedures. It is our policy to charge a $300.00 cancellation fee if given less than 72 hours notice. We will waive this fee if we are able to fill your procedure time; however, there is no guarantee that we will be able to do that in such a short amount of time. If you are scheduled for an office appointment, we must receive a notice of cancellation at least 24 hours in advance. Our policy is to charge for missed appointments at the rate of a normal office visit. The charge for a late cancellation/no show procedure or appointment will be billed directly to you and not to your insurance. Please help us serve you better by keeping scheduled appointments.

I understand the above cancellation fee. Please initial (required):

Ancillary Services:
Please be aware that there may be a charge involved for ancillary services such as multiple telephone calls, extended telephone conversations, completing disability forms and/or forms related to your care, and drafting letters on your behalf.

Patient Balances:
If payment is not received within 30 days of the statement, a late fee will be applied to your balance as follows:

  • Patient Balances of $0.01-$500.00 will incur a $10.00 late fee each month until payment is received
  • Patient Balances greater than $500.00 will incur a $25.00 late fee each month until payment is received

Thank you for taking the time to review our Financial Policy. Please let us know if you have questions or concerns.

I have read and understand the Financial Policy in full.

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Peninsula GI. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment, or an electronic copy, is to be considered as valid as an original.

I understand that I am providing my consent via e-signature by typing my name and clicking submit.

Signature / E-Signature

IP Address