1. All co-payments are due at the time of visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered a violation of the contract you have with your insurance company. Our office accepts cash, credit and debit cards.
2. Co-insurance and unmet deductibles are due prior to scheduled surgeries and procedures. Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.
3. You are 100% responsible for payment of charges for services you receive from our office.
4. In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit. If you do not have insurance or
do not present a valid insurance card, you will be responsible for payment at the time of service. We will provide you with a copy of our billing form so that you can obtain reimbursement from your insurance company.
5. It is your responsibility to ensure that our physicians are in your insurance network.
6. If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our provider.
7. Payment is due for rendered services 10 days from receipt of your billing statement. Outstanding balances must be paid in full prior to any additional visit unless arrangements have been made with our billing department.
8. There is a service fee of $35 for each time a check is returned. The bank may return your check up to three times before considering it nonnegotiable. Your insurance company does not cover this fee.
9. A scheduled appointment means that time has been reserved for you. Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment. Cancellations for scheduled surgery and in-office procedures must be received at least 7 days prior to the scheduled surgery date and time.
10. Patients who fail to keep or cancel a scheduled appointment may be charged a $25.00 No Show Fee. There is a $400.00 cancellation fee for scheduled surgeries & $100.00 cancellation fee for in-office procedures that are cancelled less than 5 business days from the date and time of surgery/procedure unless cancellation is due to insurance denial or medical necessity.
11. Medical records requests must be received in writing at least 72 hours prior to the date needed. Fees for medical records are set depending if patient has an outstanding balance and/or an attorney is requesting on your behalf. Fees must be received prior to record delivery. No more than 5 pages may be faxed.
12. Administrative Services: There is a $10.00 charge for each required Administrative Service, payable prior to service completion. This Administrative Service Fee covers specific administrative services such as forms completion for medical leave and disability (EDD Form and EDD extensions), DMV disabled person placard, and any other administrative items not covered by insurance.
13. HMO/PPO: ALL CO-PAYMENTS ARE DUE AT THE TIME OF YOUR APPOINTMENT (S). We are in-network with most, but not all insurance plans. You are responsible for verifying that Valley Foot & Ankle Center is in-network with your plan. If you are an HMO member, you will not be billed as long as we have a unused & valid referrals. Please note: You must have your referral at the time of the visit or your plan requires that we ask you to reschedule. PPO patients will only be responsible for their remaining deductible amount, co-payments and co-insurance as long as they have verified with their insurance that our physician is in their plan.
14. SELF-PAY: Payment in full is due at the time of service if you do not have health insurance coverage.