PATIENT BILLING: ALL CO-PAYMENTS, CO-INSURANCE, OR DEDUCTIBLE AMOUNTS MUST BE PAID AT THE TIME OF SERVICE. 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 fraud. Please help us in upholding the law by paying your portion of insurance benefits at each visit. As a courtesy, our office does verify benefits with your insurance carrier; however, the insurance agreement is a contract between you and your insurance carrier. It is recommended that you verify your benefits with your carrier as well.
PHYSICIAN PHONE CALLS: Phone calls with our physician(s) are a billable service, may be billed to your insurance company, and are subject to your insurance benefits. You are responsible for your portion of insurance benefits for physician phone calls.
NON-CUSTOM DURABLE MEDICAL EQUIPMENT RETURNS: If a patient is unsatisfied with any non-custom Durable Medical Equipment item, it must be returned within 30 days per Medicare guidelines. Returns after 30 days will not be permitted. The item will only be accepted as a return if it is in returnable condition. Any custom durable medical equipment item including custom orthotics MAY NOT BE RETURNED for any reason. Any payment made towards an order of orthotics shall be non-refundable.
MEDICAL RECORDS/FORMS: We will provide copies of patient records at the patient’s request. Please provide our office 48 hours to complete your request. Additional Forms such as Disability, Accident Claims or forms requiring a “Physician Statement” will incur a $25 fee. You will be charged a $5 fee for digital X-Rays provided on CD.
COPY FEE: We will provide copies of patient records at the patient’s request. Copies of records may be subject to a $0.25 per single page copy fee. You will bear complete financial responsibility for any fee(s) incurred.
COLLECTIONS FEE: You will be sent up to three notices of your financial responsibility (co-payments, co-insurance, deductible, non-covered services) after payment and/or explanation of benefits (EOB) is received from your insurance company/companies. After the third and last notice, your account will be forwarded to our collection agency. If your account is sent to a collection’s agency, a 40% fee will be added to your account. You bear complete financial responsibility for any fee(s) incurred.
Payment arrangements can be made on a case-by-case basis. We accept the following payment methods: Cash, check or Visa/MasterCard/Discover/AMEX. An additional $50.00 will be added to your statement if the check is returned from your bank. We do not accept starter checks. If your insurance company sends payment to you, the patient should be forwarded to our office to be applied to your balance.
PRIVACY STATEMENT: Any information disclosed in your records will remain confidential and will not be used for any other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.
PATIENT ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICES: By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have (or had the opportunity to read if I so chose) and understand the Notice and agree to its terms.