FINANCIAL / BILLING POLICIES (updated 2023)

Please read, initial each item, and sign at the bottom

Co-pays are due at the time of visit. It is your responsibility to be aware of any limit on the # of osteopathic treatments your insurance will cover. (Initial):*

If you do not have insurance, you will be expected to pay your balance in full at the time of your visit [unless you have signed a payment agreement]. (Initial):*

Denver Osteopathic & Sports Medicine Center is NOT a participating MEDICAID, Kaiser, Tricare, or OptumCare provider. Any balance incurred as a result of the aforementioned insurances will be considered the patient's responsibility and billed at the self-pay rate. (Initial):*

Whenever a patient balance is accrued, you will be sent a monthly statement from our office. Payment is to be made in full at that time or, if needed, you may contact us to set up a payment agreement. If the patient balance remains unpaid after 90 days, you will be sent a late notice with a collections submission date. If we receive no response, a 10-day final notice will be sent. If/when all attempts fail and payment is not made in a timely manner, we reserve the right to send your account to collections. You will be responsible for any additional collection agency fees and/or charges incurred, including reasonable attorney costs, if applicable. (Initial):*

[I have read and understand the above information] Signature*

Date*

Date

Full Name*

Consent for Use and Disclosure of Personal Health Information

This form authorizes us to use and disclose your protected health information (PHI) for the purposes of healthcare operations, treatment, and payment activities.

Before signing, please read our notice of Privacy Policies (following this signature page) to gain a clear understanding of how we may use and disclose your PHI.

For questions concerning our Notice of Privacy Policies, please contact our office (303) 991-4651.

Full Name*

Telephone*

Address*

Apartment/Unit # (if applicable)

City*

State*

Zip*

SSN*

Email*

example@example.com

[I have read DOSMC's Privacy Policy and I consent to its use of my PHI for the purposes of healthcare operations, treatment, and payment activities.] Signature*

*If this consent is signed by a parent or guardian on behalf of the patient, please complete the following:

Parent or Guardian Name

Relationship to Patient

Acknowledgement of Receipt of Notice of Privacy Policies

I have received and reviewed a copy of Denver Osteopathic and Sports Medicine Center's Notice of Privacy Policy Policies.

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Date*

Date