Your clear understanding of our Financial Policy is important to our professional relationship. We are a Medicare provider and also a provider for most PPO and HMO plans in our area. It is your responsibility to make sure we are on your insurance plan. If your insurance requires a referral or prior authorization, it is your responsibility to make sure that it is in place prior to your appointment. We will be glad to assist you if you need help.
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. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan, we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
MEDICARE: We are a participating Medicare provider. Medicare as well as your secondary (if any) will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying the annual deductible if it has not yet been met. You are also responsible for any copayments, which are usually 20% of the allowed amount for an item or service.
SECONDARY INSURANCE: Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance.
COPAYMENTS AND DEDUCTIBLES: All co-payments and deductible must be paid at the time of service. This arrangement is part of your contract with your insurance company.
SELF-PAY: If you are a self-pay patient all charges incurred must be paid in full at the time of service.
Complete payment for all medical soft goods, medical products and supplies are due at the time they are dispensed.
There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.
NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered medical necessary by Medicare or other insurers. You are responsible for payment of the services.
CLAIM SUBMISSION: We will submit your claims and assist you in any way we reasonably can to help get your claim paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance pays your claim. Your insurance benefit is a contract between you and your insurance company.
PATIENT BILLING: You will be sent up to three notices for your financial responsibility (co-insurance, deductible) after payment and/or explanation of benefits (EOB) is received from your insurance company/companies. After the third and last notice, your account may be forwarded to collections. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office. We accept the following payment methods: Cash, Check, Visa, Mastercard, Discover Card and HSA/FSA Cards.
OUTSTANDING BALANCES: It is your responsibility to keep your account with us current. This includes all outstanding balances resulting from co-pays, deductibles, and non-covered services. If your account becomes 90 days past due, your balance will need to be paid before you are able to schedule another appointment.
APPOINMENT CANCELLATION POLICY: A 24-hour notice is requested for cancellations of appointments. If you fail to show for an appointment, you personally may be charged a $25.00 no-show fee. We will try to accommodate you in rescheduling your appointment as soon as possible.
I have read the above policy regarding my financial responsibility to Foot First Podiatry for medical services provided. I agree to pay Foot First Podiatry any balance unpaid by my insurance carrier for myself or the below named person.
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 Private Practices, and that I have (or had the opportunity to read if I so chose) and understand the Notice and agree to its terms.
Assignment of benefits: I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Foot First Podiatry, all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductible, co-payments, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.