Patient Financial Policy. You must complete a New Patient Registration form providing all personal information required and complete any insurance information as required on the form. This information must be provided to the office at least 2 days prior to your appointment for verification of medical insurance. In the event the office is not provided with this information, you will be responsible for all charges not covered by your insurance. Hoosier Foot and Ankle will attempt to verify insurance benefits and eligibility prior to your visit; however, these verifications are NOT a guarantee of payment. ____ You are responsible for understanding your insurance policy and checking with your insurance carrier for all authorizations/referrals/pre-certifications needed to seek treatment with Hoosier Foot and Ankle physicians. As a courtesy we will call your insurance to verify eligibility, deductibles and any out of pocket costs. For commercial insurance plans with a deductible of more than $500 we may require a down payment of prescribed devices/services in addition to your co-pay prior to seeing the doctor. ____ Self pay patients are responsible for payment of ALL office visits and services at the time of service. We accept most credit cards, cash or personal checks. ____ Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with all insurance carriers provided. You are agreeing to have your insurance company(s) pay Hoosier Foot and Ankle directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. ____ Please honor our 24 hour appointment rescheduling or cancellation notice requirement. Repetitive, broken or cancelled appoints may result in a discharge from Hoosier Foot and Ankle offices. ____ Hoosier Foot and Ankle is contracted with many commercial insurance carriers and health care plans including Medicare and Medicaid. We will bill your insurance plans and will require you to pay any co‑pay required for specialty providers stated on your insurance card at time of service. Co‑insurance, non-covererd services and deductible amounts, determined by your insurance company, will be due to Hoosier Foot and Ankle within 30 days of receiving your billing statement. If you are seeing our doctors on an ‘Out of Network” basis, you will be subject to out of network rates. ____ Not all services are a “cove...
Patient Financial Policy. You must provide personal (address, phone numbers, etc) and/or insurance changes (carriers, networks, id numbers, etc) to the office at least 2 days prior to your appointment. In the event the office is not informed, you will be responsible for any charges denied. You are responsible for all authorizations/referrals/precerts needed to seek treatment with ACADEMY FOOT & ANKLE SPECIALISTS physicians. If you are unsure if your referral or precert is current please check with one of our representatives. Your portion of payment for ALL office services is due at the time of service. We will accept VISA, MasterCard, cash or check. All benefit quotes or prices given are merely an estimate and are not a guarantee and are subject to change, based on your insurance carriers determination, there may be an additional balance due. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with an assignment of benefits. You are agreeing to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. You are encouraged to contact your designated patient account representative at our office with any questions. Please honor our 24 reschedule notice, as there may be a charge for appointments broken or cancelled without 24 hours advanced notice. Repetitive broken or cancelled appoints and/or non-compliance may result in transfer of your care to an alternative practice. We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will require you to pay the co- pay/co- insurance/deductible at the time of service. Your upfront portion will be calculated based on your insurance benefit/limits and our negotiated fee agreement with your carrier. If you are seeing our doctors on an ‘Out of Network” basis, you will be subject to out of network rates. Once the claims are processed by your insurance there may be an additional balance we will bill you for this amount. Not all services are a “covered” benefit in all insurance policies; some plans even impose a waiting period before covering services. In the event your health plan determines a service to be "not covered/pre-existing," or you do not have an authorization, you will be responsible for all charg...
