It is the policy of Suburban Foot Physicians, Inc. to have a Financial/Office Policy that clearly outlines patient and practice financial responsibilities. We are committed to providing our patient with the best possible medical care while minimizing administrative costs.  This policy has been established with these objectives in mind, and to avoid any misunderstanding or disagreement concerning payment of professional services. Please do not alter this form in any way. If you have any questions, our office staff will be happy to assist you.

• Suburban Foot Physicians, Inc. participates with numerous insurance companies as well as Medicare.  For patients that are members of one of these plans, our office will submit a claim for the services rendered.  If a patient has insurance that Suburban Foot Physicians, Inc. does not participate in, our office will be happy to file a claim with the insurance company for you.  It is the patient’s responsibility to pay any co-payment, deductible or any portion of the charges as specified by the plan at the time of visit.  Suburban Foot Physicians, Inc. will follow-up with your insurance company to continue processing, however, any claim which remains unpaid after 90 days will become patient responsibility and further insurance follow-ups is the responsibility of the patient.
• Any patient that is not covered by an insurance plan must pay for services rendered at the time of the appointment.
• It is Suburban Foot Physicians, Inc.’s policy to collect payment due at the time of service as well as any unpaid patient balances.  Payment may be made by Cash, Check or Credit Card (VISA, Mastercard, Discover). Payments may be conducted over the phone if requested.
• The fee for a returned/bounced check is $25 (amount is subject to change without notice).
• Any remaining balance unpaid by insurance is the patient’s responsibility. If it becomes necessary for the account to be sent to collection, the full collection fees, court fees and attorney fees will be added to the balance due from the patient. An additional 35% of the total due will be added for the collection agency fees.
• If a patient’s account becomes delinquent or has been forwarded to a collection agency, the account will be placed on a restricted status.  Suburban Foot Physicians, Inc. will continue to provide medical care to the patient until the current medical condition is resolved or another provider can be found, however, the cost of this care must be paid at the time of service.
• In case of financial hardship Suburban Foot Physicians, Inc. might contract a payment agreement plan if the patient/guarantor qualifies and signs a statement declaring financial hardship.
• It is the patient’s responsibility to provide Suburban Foot Physicians, Inc. with any insurance changes and present their insurance card and photo identification when required.
• It is the patient’s responsibility to ensure any required referrals or pre-certifications for treatment be provided to the practice prior to the visit.  Visits might be rescheduled, or the patient will be financially responsible due to the lack of a referral or pre-certification/authorization.
• In the case that the patient’s treated condition is the result of injury where an entity other than their health insurance is liable for payment, it is the patient’s responsibility to ensure any required paperwork be provided to the practice prior to the visit.  This includes workman’s comp cases.  Visits might be rescheduled, or the patient will be financially responsible due to the lack of appropriate paperwork.
• Our staff is happy to help with insurance questions relating to how a claim was filed or regarding any additional information the carrier might need to process the claim.  Please contact your insurance company for any questions relating to what might or might not be a covered service on your plan.
• It is important to keep your appointment scheduled.  Failure to notify our office of a cancellation of an appointment with less than 24 hours notice might result in a $50 charge (amount is subject to change without notice).  3 Short-notice cancellations within 1 year will incur an automatic $50 charge.

• ASSIGNMENT AND RELEASE: I authorize payment for services rendered to me or my dependants by Suburban Foot Physicians, Inc. to be paid directly to Suburban Foot Physicians, Inc. I understand that all charges incurred are the personal responsibility of the patient/guarantor. Commercial insurance is filed as a courtesy to the patient. The patient/guarantor is responsible for all residual balances including but not limited to co-pays, deductibles, co-insurance and services or charges not paid by insurance for any reason, after consideration of contractual adjustments.
• I am aware the office does not bill Medicaid or Public Aid and I agree to be responsible for charges not covered by other insurance.
• I am aware the office does not bill HMO insurance and I agree to be responsible for payment of all charges.
• I agree to pay all costs of collection including collection agency fees, attorney fees, and costs incurred by Suburban Foot Physicians, Inc. An additional 35% of the total due will be added.
• I authorize Suburban Foot Physicians, Inc. and its physicians to release any information necessary to any third party payor (insurance) or their contracted agents to validate or determine benefits payable.
• I hereby give my permission to have my feet examined and treated medically, surgically, or orthopedically.
• I authorize clinical photographs to be taken to enhance the evaluation and management of the medical condition being treated.  Photographs will be maintained as part of my confidential medical record.
• I authorize and consent to ambient audio recording to be used during appointments to enhance documentation of the visit.
  
• I give permission for retrieval of medical information from other entities such as other doctor offices, pharmacies, etc.
• I acknowledge that taking video or photos of procedures or staff is not allowed without prior consent/approval.
• I acknowledge that a copy of the Notice of Privacy Practices is available in the office and that I have had the opportunity to read and understand the Notice.
• I understand I might be charged $50 if I fail to notify the office of my appointment cancellation with 24 hours notice. 3 Short-notice cancellations within 1 year will incur an automatic $50 charge.
• I acknowledge that the physicians do not take emergency call outside of regular office hours.
• I have read, understand, and agree to the Financial/Office Policy and will be provided a copy per request.