NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or be considered reasonable or necessary by Medicare or other insurers. Your insurance has the power to deem some medical services unnecessary for your health. You are responsible for payments for these services.
PHYSICIAN PHONE CALLS: Phone calls with our physician(s) are a billable service, may be billed to your insurance company/companies, and are subject to your insurance benefits. You are responsible for your portion of insurance benefits for physician phone calls.
CHARGES YOU MAY INCUR: If we are asked to complete additional forms or reports for you, there will be additional charges. Form and report completion fees are collected when the request is made. These fees will NOT be billed to your insurance company. Additional charges will be assessed for the following: Disability Forms, FMLA forms, Copies of Medical Records, Returned Checks, Attending Physician Statement, and over-the-counter medical supplies.
DURABLE MEDICAL EQUIPMENT/CUSTOM ORTHOTICS: Durable Medical Equipment (DME) and custom orthotics may not be returned. Deposits are non-refundable, unless covered by insurance.
CANCELLED/MISSED APPOINTMENT FEE: If you cannot keep your appointment time, please call our office at least 24 hours PRIOR to your scheduled appointment time. THERE MAY BE A $35 FEE FOR APPOINTMENTS CANCELLED/RESCHEDULED WITHIN 24 HRS OF YOUR APPOINTMENT TIME. ADDITIONALY, THERE MAYBE A $50 FEE IF YOU MISS A SCHEDULED APPOINTMENT.
Missed appointments are considered no calls / no shows. You will bear complete financial responsibility for any fee(s) incurred. Payment will be due prior to rescheduling. If you cancel or reschedule 3 or more appointments or you miss your appointment you may be required to pay a $50 deposit to hold any future time slots. Deposit will be non-refundable if an appointment is missed, cancelled, or rescheduled within 24 hours of the scheduled appointment time. Repeated missed, late, rescheduled, or cancelled appointments may result in dismissal from the practice.
PATIENT BILLING: You will be sent up to three (3) statements for any remaining balance of your financial responsibility 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. If your account is referred to collections, you will be held responsible for the collection processing fee of twenty-three (23%) in addition to your balance. We may contact you via telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. As well as text messages or emails using the email address provided to us. Methods of the contact may include pre-recorded/artificial voice messages and/or the use of automatic dialing device as applicable.
If you have any difficulties resolving your bill, please contact our billing department. We accept the following payment methods: Cash, Check, VISA, MasterCard, Discover, American Express and Care Credit. An additional $35 fee will be added to your statement if your check is returned for insufficient funds. In the event your insurance company should happen to send payment to you, the patient, we expect that you will forward it to our office to be applied to your balance.
MARKETING STATEMENT: By signing my name below, I consent to being sent periodic electronic mail and/or SMS messages that may be of interest to me based on my diagnosis or for general informational purposes. If you DO NOT wish to receive these communications, please request an OPT-OUT FORM from our office.