Thank you for choosing Advanced Family Foot & Ankle as your health care providers. We are committed to your treatment being successful. The following is a statement of our Financial Policy that we ask you to read, agree to and sign prior to any treatment.
Payment is due at the time services are rendered, including co-payment and deductibles. We do bill insurance plans as a courtesy. Types are PPO, POS, and HMO. We accept cash, checks, credit cards, and debit cards.
It is your responsbility to verify with your insurance plan/carrier prior to each appointment that our group and the individual doctors are participating providers. Please verify if any services such as office visits, x-rays, and procedures require pre-authorizations. Some plans require pre-authorizations or referrals from the patient's family physician.
Written or verbal Authorizations from insurance plans or management groups are not a guarantee of payment. All claims are reviewed by the insurance carriers after services are rendered and authorizations can be denied at the time of review. Denied claims become the patient's responsibility.
Statements are mailed after the insurance company has paid their portion. The account is then payable within 30 days. Overdue accounts are subject to a $15.00 fee. Accounts 90 days in arrears will be subject to collection by an external agency unless financial arrangements are made with our office manager.
All supplies dispensed which are not billable to insurance must be paid for at the time they are dispensed. There are no refunds or exchanges on any supplies dispensed.
We recommend you verify with your insurance carrier whenever our office refers you to outside laboratories, hospitals, physical therapy or tests to insure that you do not require any pre-authorization.
There is a $25.00 charge for any and all forms filled out by our office. Please allow 15 days for completion of forms.
There is a $25.00 charge for appointments cancelled less than 24 hours notice.
There is a $50.00 charge for patients who no show to surgery without a cancellation notice.
There is a charge for requested, copied X–rays or medical records. All requests must be submitted in writing and please be advised, according to state law, copied records will be processed within 10 business days.
No pain or narcotic medication will be refilled over the phone. You must make an appointment with the treating doctor
I HAVE READ THE ABOVE AGREEMENT AND AGREE TO THE TERMS AND CONDITIONS AS SET FORTH BY ADVANCED FAMILY FOOT & ANKLE.