Call us directly: 620-431-2500

Chanute - Humboldt - Iola - Burlington - Neodesha     
View Locations

The Ashley Clinic: Patient Financial Policy

Self-Pay Accounts: Self-pay accounts are patients without an insurance card on file. All accounts are deemed “self-pay” absent the patient providing proof of coverage. A pre-determined minimum payment, posted in the reception area, is required at the time of service. (This payment will be applied to the total charges actually incurred, which may be more than this down payment). As a courtesy, after the initial minimum payment, the balances may be paid in equal installments over a 90 day period. 

Network Insurance Plans Contracting with Ashley Clinic (PPO/Blue Cross & Blue Shield): The patient is expected to present an insurance card at each visit. All co-payments are due and payable at the time of service.

Insurance Plans not Contracting with Ashley Clinic: The patient is expected to present an insurance card at each visit. We will submit a claim to your insurance company. The patient is responsible for a $25 good faith payment at the time of service. After payment of all insurance coverage, patient will be billed for the remaining balance owed. As a courtesy, the remaining balances may be paid off in equal installments over a 90-day period. 

Kansas Medical Assisted Programs: The patient or their guardian is responsible for providing proof of ongoing coverage. Absent proof, a patient is deemed to be “self-pay.” Dependent upon the specific plan, co-pays are required to be paid at the time of service.

Medicare: The Ashley Clinic will file claims and accept your Medicare assignment. The patient may be responsible for deductible/coinsurance amounts. Also, due to Medicare restrictions, certain services may not be covered. If there is a significant likelihood the service is not covered, the patient may be asked to sign a Medicare waiver, which acknowledges the responsibility for payment belongs with the patient. All deductible amounts shall be billed as with all other accounts. It is anticipated that balances will be paid in equal installments over a 90 day period.

Automobile Accident Cases: The automobile insurance company will be filed as a primary insurance, with your health insurance being filed after personal injury benefits have expired. If a patient has no health insurance above automobile insurance payments, their account will become treated as a “self-pay” account, subject to the policy outlined above.

Referrals: If your insurance company has designated a primary care physician (PCP), you are required to provide a referral form from your PCP prior to your clinic visit. If this referral form is not provided prior to the clinic visit, the patient will be asked to either reschedule the appointment or pay for the visit at the time of service, subject to the “self-pay” policy described above. Improper presentment of referral forms can result in noncoverage of insurance benefits.

Payment Options:

1. Health Insurance and Other Payment Plans:

As a service to our patients, the Ashley Clinic will file your insurance claims. These claims will be filed with health insurance policies, automobile insurance policies, Workman’s Compensation policies, and other payment plans. Unfortunately, not all services are paid by each insurance company or payment plan. Ultimately, the patient is financially responsible for the services provided. The clinic will send a final statement to the patient, once the insurance company or payment plan has responded to our claim. The patient, upon receipt of that statement, is obligated to pay the remaining balance in full.

2. Payment Plan:

The Ashley Clinic's primary policy is payment in full for services, as billed. This policy allows the clinic to provide the most well-rounded medical care as is reasonably possible for its patients. However, the clinic recognizes that individuals may not always be in a position where they can pay an account in full. In such situations, the clinic offers a payment plan policy as follows:

Office procedures, surgical procedures, and prenatal care:

The patient may be required to prepay for certain elective or cosmetic surgical procedures.

The patient will be required to pay at least 50% of the prenatal care and delivery (not covered by insurance) prior to the time of delivery.

It is Ashley Clinic's policy that the balance due, after the processing of insurance, be paid in full as billed. In some circumstances the clinic recognizes that a patient may not be able to pay their balance in full. In that instance, upon consultation with the Patient Accounts Department, a payment plan may be authorized. To arrange for such a payment plan, the patient should contact our Patient Accounts Department at (620) 431-2500.

As a convenience for the patient, the clinic can arrange an automatic draft to be set up for your checking or credit card account. There will be a service charge applied to any returned checks.

3. Credit Cards:

As a convenience for our patients, the Ashley Clinic gladly accepts your bank debit card, Visa, MasterCard, or Discover cards.

4. Care Credit:

Ashley clinic gladly accepts CareCredit as a method of payment.  Please contact the Patient Accounts Department or for more information.

Delinquent Accounts:

In situations where account balances are outstanding longer than 90 days, they will be considered for collection referral and you may be responsible for any collection fees from outside agencies and attorneys, unless other prior arrangements have been made with the Patient Accounts Department at (620) 431-2500. In unusual circumstances, the clinic reserves the right to require patients to be on a “cash only” basis for future services. In situations of significantly delinquent accounts, a process to terminate the doctor/patient relationship may commence.

The purpose of this financial policy is to help ensure the clinic’s ability to provide quality healthcare to all patients. Unpaid accounts diminish the resources available to provide quality healthcare. Thank you for your cooperation. If you have questions, please do not hesitate to contact our Patient Accounts Department at (620) 431-2500.



Contact the Ashley Clinic at (620) 431-2500 for answers to your questions about medical care or to schedule an appointment. You may also use our Contact Page for any NON-MEDICAL communications. The Ashley Clinic's primary policy is payment in full for services, as billed.