Financial Policy for Foot & Ankle Physicians of Ohio
Thank you for choosing our office to provide you with medical care. We are committed to serving you with skill and high quality care. The medical services provided by our office are services you have elected to receive which may imply a financial responsibility on your part.
INSURANCE: We participate in most insurance plans, however we encourage you to check with your insurance carrier to confirm our participation. We require that you bring your insurance card with you to each visit so that we may confirm your eligibility. If you do not present your card and it is determined that you do not have coverage, you will be responsible for the charges incurred at the time of the service. You are responsible for keeping the office informed as to any changes in your insurance contract or carrier information. Please be aware that your insurance policy is a contract between you and your insurance carrier. We are pleased to provide the service of submitting claims for our patients; however we remind you that you are ultimately responsible for payment of any services provided to you.
COPAYMENTS AND DEDUCTIBLES: Most insurance plans require that the insured patient pay a co-payment for office visits and other specified services such as x-rays and injections. Foot & Ankle Physicians of Ohio is required by the plans we contract with to collect your co-pay and any unmet deductible at the time of your service. Any questions you might have regarding co-payments and deductibles should be directed to your insurance company or your employer's human resources department. Knowing your insurance benefits is your responsibility.
MEDICARE: We are a participating Medicare provider. Medicare, as well as any secondary insurance, will be billed for you. Patients are responsible for paying their annual deductible if not previously met as well as any co-payments, which are usually 20% of the allowed amount for an item or service.
SECONDARY INSURANCE: Your medical claim will be forwarded to any secondary insurance after payment and/or explanation of benefits (EOB) is received from your primary insurance company.
NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payments of these services.
REFERRALS/AUTHORIZATIONS: We are required to follow all guidelines of a managed care plan that may require when you visit a specialist, you must have a referral from your primary care physician prior to seeking specialty care. If your plan requires a referral, and if you do not have a referral from your primary care physician at the time of the visit, you will be financially responsible for all services due in full upon completion of the visit. You may also be given the option to reschedule your appointment.
CLAIM SUBMISSION: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request in a timely manner. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.
PATIENT BILLING: You will be sent up to three notices for your financial responsibility (co-insurance/deductible) after payment and/or explanation of benefits receivedfrom your insurance company/companies. After the third and last notice, your account may be forwarded to collections. Please let the billing office (EOB)is know if you have any difficulties resolving your bill. Payment arrangements can be made on a case-by-case basis. We accept the following payment methods: Cash, Check, VISA/MasterCard/Discover, and HSA/HRA. An additional $25.00 will be added to your statement if your check is returned for insufficient funds. In the event your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance.
CHARGES YOU MAY INCUR: If we are asked to complete additional forms or reports for you, there will be additional charges. Form and report completion fees collectedwhen the request is made. These fees will NOT be billed to your insurance company. Additional charges will be assessed for the following: Disability are Forms,FMLA forms, Copies of Medical Records, Returned Checks, Attending Physician Statement, Over-the-counter medical supplies, and Shoe Restocking.
DURABLE MEDICAL EQUIPMENT/CUSTOM ORTHOTICS: Durable Medical Equipment (DME) and custom orthotics may not be returned.
I have read and agree to abide by the above financial policy and have been given an opportunity to ask questions on any points that I did not understand. I agree to pay Step Lively Foot & Ankle Centers any balance unpaid by my insurance carrier for myself or the below named person.
ASSIGNMENT OF BENEFITS: I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Foot & Ankle Physicians of Ohio, all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or noncovered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of mymedical information to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I understand that it is my responsibility to inform the doctor's office if there is a change in my health insurance information.
I acknowledge all copayments, balances and/or deductibles are due at the time of serivce.