Financial Policies and Office Policies

FINANCIAL POLICIES AND OFFICE POLICIES

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policies and Office Policies is important to our professional relationship. Please ask if you have any questions about our fees, your financial responsibility, or our office policies.

PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. Our staff will ask you to verify your billing information at each and every visit. Current information is essential in order for us to contact you regarding your treatment and for obtaining timely payment from your insurance company.

BASIC POLICY: Payment for services is due in full at the time service is provided in our office.

FORMS OF PAYMENT: We accept Cash, Checks, Visa, MasterCard, American Express, and Discover.

FOR PATIENTS WITH INSURANCE: We will bill most secondary insurance companies for you. CO-PAYMENTS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid, or why it paid less than anticipated for care. If your insurance carrier has not paid within 60 days of billing, professional fees are due and payable in full from you. This billing is performed as a courtesy to you, and ultimately the patient is responsible for the charges.

MEDICARE PATIENTS: We will bill Medicare for you. We will also bill secondary insurance carriers for you. ALL CO- PAYMENTS AND DEDUCTIBLES ARE DUE AND PAYABLE AT THE TIME SERVICE IS PROVIDED. This billing is performed as a courtesy to you.

NON-COVERED SERVICES: Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided, or upon notice of insurance claim denial.

PAST DUE BALANCES & PAYMENT PLANS: We certainly do understand that many of us have financial difficulties. We will make every attempt to work with you. However, if you fail to cooperate with us, you may be discharged from the practice and your outstanding bill referred to a collection agency. A past due balance is any amount owed from a prior visit where insurance is not pending, the account may have been sent to collections, or an insurance payment has not been received by MK Orthopaedics Surgery and Rehabilitation within 90 days. Patients are encouraged to pay outstanding balances in full; however, payment plans may be available. Balances on accounts with payment plans where payments conform to the plan are not considered past due balances.

PERSONAL INJURY CASES: This office does not bill third-party insurance carriers in regards to auto accidents, or other liability or lawsuit-related cases. YOU ARE RESPONSIBLE FOR PAYMENT AT THE TIME OF SERVICE. WE DO NOT ACCEPT LIENS.

WORKERS’ COMPENSATION: If your injury is work-related, we will need the case number and carrier name prior to your visit to bill the workers’ compensation insurance company.

YEARLY HEALTH CHECKS: Periodic preventative health checks may or may not be covered under your health insurance policy; however, they may be required by your physician.

1 TREATMENT OF MINOR CHILDREN: A parent or legal guardian must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment of the account.

REFERRALS: If your insurance plan requires a referral from a primary care physician, it is YOUR responsibility to obtain the referral prior to your appointment and to have it with you at the time of the appointment. If you do not have your referral, you may have to reschedule your appointment.

FINANCIAL ARRANGEMENTS FOR SURGERY: If your physician recommends surgery, you will be contacted by our Surgical Coordinator to discuss any paperwork, arrange any needed tests prior to surgery, and complete all pre- certification authorization that may be needed.

FRACTURE CARE: Some insurance companies require that fracture care billing be done on a “global” basis. This means that for a pre-determined amount of time, all professional services related to the fracture care are included within an initial fee paid by the insurance company. X-Rays, casting/splinting, along with related supplies are not included within the global fee and are billed separately. Please note, that injections, joint aspirations, and fracture care are all procedures listed as “surgical” for billing purposes by insurance companies. Though these services may be provided in the office or emergency room, they are generally listed on your explanation of benefits or bill as “surgical.”

MISSED APPOINTMENTS: In fairness to other patients and the doctor, we require at least 24 hours’ notice to cancel appointments. You may be charged $26.00 for a missed appointment if not given at least 24-hour notice. You may be dismissed from the practice for missed appointments. Most insurance companies do not cover this fee.

RETURNED CHECKS: Our bank charges us whenever a patient presents a check that does not have funds available. Therefore, we must charge a $25.00 handling fee for any returned check.

FORMS AND LETTERS: There will be a fee assessed for completion of forms or letters. This includes Disability paperwork and FMLA paperwork. This fee will be collected in advance. Please allow at least 7 working days. Most insurance carriers do not cover this fee.

RECORD COPIES: There is a copy fee mandated by the state for copying of medical records. This does include x-ray copies. In accordance to HIPPA polices, please note that when requesting copies of medical records you will be required to sign a Medical Records Release Form. Please also note that in accordance to HIPPA policies, if you are a parent or legal guardian requesting medical records for your child and the child is over 18 years old, you are NOT permitted to sign for the release of their medical records.

ACKNOWLEDGMENT OF FINANCIAL POLICIES AND OFFICE POLICIES OF MK ORTHOPAEDICS SURGERY AND REHABILITATION

I understand and agree that, regardless of my insurance policy, I am responsible for the entire balance on my account, for all professional services provided to the patient (or myself). I have read (or had the opportunity to read and chose not to) all the information contained in the Financial Polices and Office Policies of MK Orthopaedics Surgery and Rehabilitation.

Patient Name (Print): Patient or Authorized Representative (if applicable Signature: Date: