Common use of Patient Financial Policy Clause in Contracts

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 charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you MUST notify us of your designated PRIMARY policy. Pre-scheduled Surgical procedures require pre- payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Any payment exceptions will be agreed upon in writing. We are happy to discus repayment options. PAST DUE accounts are subject to collection proceedings including the credit bureau. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Academy Foot & Ankle Specialists Doctor-Patient relationship. There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms of payment. Restitution of “Theft-by-Check” will be requested from the District Attorney’s Office. ACADEMY FOOT & ANKLE SPECIALISTS issues patient refunds by credit card or check within 90 days of a completed investigation of the potential overpayment. Refunds are made once all dates have been paid in full by the insurance or patient. ONLY UNWORN and NON-custom items are returnable within 3 days of receipt. Custom items are non-returnable. Medical Records and X-Rays are the property of the office. We can make arrangements for you to get a copy with 30 days notice. X-rays are $10.00 per film per copy. Medical records are $2.50 per page per copy. These charges are not covered by your insurance and all requests should be made in writing. Disability forms or work forms that need to be completed by our office will incur a charge of $10.00 per form per occurrence. Minor Patients if unaccompanied non-emergency treatment will be denied unless appropriate consent has been received and charges have been pre-authorized.

Patient Financial Policy. You must provide personal (address, phone numbersnumber, etc.) and/or insurance changes (carriers, networks, id ID numbers, etc.) to the office at least 2 days prior to your appointmentoffice. In the event the office is not informed, you will be responsible for any charges denied. — You are responsible for all authorizations/referrals/precerts prior authorizations needed to seek treatment with ACADEMY FOOT & ANKLE SPECIALISTS Obstetrics and Gynecology of North Texas physicians. If you are unsure if your referral or precert is current unsure, please check with one of our representativesa staff member. 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 Please contact your designated patient account representative at our office with any questions. — Please honor our 24 24hour 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 appointments may also result in transfer of your care to an alternative practicea charge. — 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- co-pay/co- 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 physicians on an ‘Out of Network“out-of-network” basis, you will be subject to out of network rates. Once the claims are processed by your insurance insurance, there may be an additional balance we 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 charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans insurance carrier for clarification of benefits prior to services rendered. — Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you MUST must notify us our office of your designated PRIMARY primary policy. — Pre-scheduled Surgical surgical procedures require pre- pre-payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospitalhospital by our physicians, we our office will bill your health planinsurance carrier. Any balance due is your responsibility. — We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to please contact us our office promptly for assistance in managing your accountrepayment of balances due and payment options. Any payment exceptions will be agreed upon in writing. We are happy to discus repayment options. PAST DUE — Past due accounts are subject to collection proceedings including the credit bureaubureaus. All fees including, including but not limited to collection fees, attorney fees and fees, and/or court fees shall become your responsibility in addition to the balance due this to our office. Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Academy Foot & Ankle Specialists Doctor-Patient relationship. — There is a service fee of $25.00 35 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms another form of payment. Restitution of “Thefttheft-by-Checkcheck” will be requested from the District Attorney’s Office. ACADEMY FOOT & ANKLE SPECIALISTS issues patient refunds by credit card or check within 90 days of a completed investigation of the potential overpayment. Refunds are made once all dates have been paid in full by the insurance or patient. ONLY UNWORN and NON-custom items are returnable within 3 days of receipt. Custom items are non-returnable. — Medical Records and X-Rays rays are the property of the officeObstetrics & Gynecology of North Texas. We can make arrangements for you to get You may request a copy of medical records with 30 days notice. Xa 30-rays are day notice and a fee of $10.00 per film per copy. Medical records are 25 for the first 25 pages and $2.50 .50/per page per copythereafter. These charges fees are not covered by your insurance and all requests should must be made in writing. Disability — Disability/FMLA forms or work forms that need needing to be completed by our office Obstetrics & Gynecology of North Texas will incur a charge of $10.00 25 per form per occurrence. — Minor Patients if unaccompanied non-emergency treatment will patients must be denied unless appropriate accompanied by a parent/legal guardian with a signed consent has been received and charges have been pre-authorizedform.

Patient Financial Policy. You must provide complete a New Patient Registration form providing all personal (address, phone numbers, etc) and/or information required and complete any insurance changes (carriers, networks, id numbers, etc) information as required on the form. This information must be provided to the office at least 2 days prior to your appointmentappointment for verification of medical insurance. In the event the office is not informedprovided with this information, you will be responsible for any all charges deniednot 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/precerts pre-certifications needed to seek treatment with ACADEMY FOOT & ANKLE SPECIALISTS Hoosier Foot and Ankle physicians. If you 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 unsure if your referral or precert is current please check with one responsible for payment of our representatives. Your portion of payment for ALL office visits and services is due at the time of service. We will accept VISA, MasterCardmost credit cards, cash or checkpersonal checks. 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 benefitsall insurance carriers provided. You are agreeing to have your insurance company company(s) pay the doctor 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. You are encouraged to contact your designated patient account representative at our office with any questions. ____ Please honor our 24 reschedule noticehour appointment rescheduling or cancellation notice requirement. Repetitive, 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 a discharge from Hoosier Foot and Ankle offices. ____ Hoosier Foot and Ankle is contracted with many commercial insurance carriers and health care to an alternative practice. We have made prior arrangements with insurers plans including Medicare and other health plans to accept an assignment of benefitsMedicaid. We will bill those your insurance plans with which we have an agreement and will require you to pay the co- pay/co- insurance/deductible any co‑pay required for specialty providers stated on your insurance card at the time of service. Your upfront portion Co‑insurance, non-covererd services and deductible amounts, determined by your insurance company, will be calculated based on due to Hoosier Foot and Ankle within 30 days of receiving your insurance benefit/limits and our negotiated fee agreement with your carrierbilling statement. 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 charges. We will attempt to verify benefits for some most specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you MUST notify us of your designated PRIMARY policy. Pre-scheduled Surgical procedures require pre- payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. ____ We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Any payment exceptions will plans must be agreed upon and in writing. We are happy to discus repayment options. ____ PAST DUE accounts are subject to collection proceedings including the reporting to credit bureaubureau(s). All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. ____ Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Academy Hoosier Foot & and Ankle Specialists Doctor-Patient and patient relationship. ____ There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms of payment. Restitution of “Theft-by-Check” NSF or any other reason will be requested from filed with the District Attorney’s Officelocal authority for collection and fines. ACADEMY FOOT & ANKLE SPECIALISTS issues ____ Hoosier Foot and Ankle will attempt to issue any patient refunds by credit card or check refund applicable within 90 days of a completed investigation of the potential overpayment, after any final office visit. Refunds are made once all dates have been paid in full by the insurance or patient. ____ ONLY UNWORN and NON-custom DME items are returnable within 3 days of receipt. Custom items are nonNON-returnableRETURNABLE. Medical Records and X-Rays are the property of the office. We can make arrangements for you to get a copy with 30 days notice. X-rays are $10.00 per film per copy. Medical records are $2.50 per page per copy. These charges are not covered by your insurance and all requests should be made in writing. Disability forms or work forms that need to be completed by our office will incur a charge of $10.00 per form per occurrence. Minor Patients if unaccompanied non-emergency treatment will be denied unless appropriate consent has been received and charges have been pre-authorizedPatient Financial Policy (cont.)

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 SAPC 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, American Express, 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- co-pay/co- 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 charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. Our office does not file to tertiary secondary insurance, unless the patient has Medicare. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you MUST notify us of your designated PRIMARY policy. Pre-scheduled Surgical procedures require pre- pre-payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in managing your account. Any payment exceptions will be agreed upon in writing. We are happy to discus repayment options. PAST DUE accounts are subject to collection proceedings including the credit bureau. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office. Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Academy Foot & Ankle Specialists Doctor-Patient relationship. There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms of payment. Restitution of “Theft-by-Check” will be requested from the District Attorney’s Office. ACADEMY FOOT & ANKLE SPECIALISTS issues patient refunds by credit card or check within 90 days of a completed investigation of the potential overpayment. Refunds are made once all dates have been paid in full by the insurance or patient. ONLY UNWORN and NON-custom items are returnable within 3 days of receipt. Custom items are non-returnable. Medical Records and X-Rays are the property of the office. We can make arrangements for you to get a copy with 30 days notice. X-rays are $10.00 per film per copy. Medical records are $2.50 per page per copy. These charges are not covered by your insurance and all requests should be made in writing. Disability forms or work forms that need to be completed by our office will incur a charge of $10.00 per form per occurrence. Minor Patients if unaccompanied non-emergency treatment will be denied unless appropriate consent has been received and charges have been pre-authorized.

Patient Financial Policy. You must provide personal (address, phone numbersnumber, etc.) and/or insurance changes (carriers, networks, id ID numbers, etc.) to the office at least 2 days prior to your appointmentoffice. In the event the office is not informed, you will be responsible for any charges denied. — You are responsible for all authorizations/referrals/precerts prior authorizations needed to seek treatment with ACADEMY FOOT & ANKLE SPECIALISTS Obstetrics and Gynecology of North Texas physicians. If you are unsure if your referral or precert is current unsure, please check with one of our representativesa staff member. 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 Please contact your designated patient account representative at our office with any questions. — Please honor our 24 24hour 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 appointments may also result in transfer of your care to an alternative practicea charge. — We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill xxxx those plans with which we have an agreement and will require you to pay the co- co-pay/co- 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 physicians on an ‘Out of Network“out-of-network” basis, you will be subject to out of network rates. Once the claims are processed by your insurance insurance, there may be an additional balance we balance. We will bill xxxx 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 charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans insurance carrier for clarification of benefits prior to services rendered. — Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you MUST must notify us our office of your designated PRIMARY primary policy. — Pre-scheduled Surgical surgical procedures require pre- pre-payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospitalhospital by our physicians, we our office will bill xxxx your health planinsurance carrier. Any balance due is your responsibility. — We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to please contact us our office promptly for assistance in managing your accountrepayment of balances due and payment options. Any payment exceptions will be agreed upon in writing. We are happy to discus repayment options. PAST DUE — Past due accounts are subject to collection proceedings including the credit bureaubureaus. All fees including, including but not limited to collection fees, attorney fees and fees, and/or court fees shall become your responsibility in addition to the balance due this to our office. Accounts no longer maintaining a financial “Good Faith” status will result in the termination of the Academy Foot & Ankle Specialists Doctor-Patient relationship. — There is a service fee of $25.00 35 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in other forms another form of payment. Restitution of “Thefttheft-by-Checkcheck” will be requested from the District Attorney’s Office. ACADEMY FOOT & ANKLE SPECIALISTS issues patient refunds by credit card or check within 90 days of a completed investigation of the potential overpayment. Refunds are made once all dates have been paid in full by the insurance or patient. ONLY UNWORN and NON-custom items are returnable within 3 days of receipt. Custom items are non-returnable. — Medical Records and X-Rays rays are the property of the officeObstetrics & Gynecology of North Texas. We can make arrangements for you to get You may request a copy of medical records with 30 days notice. Xa 30-rays are day notice and a fee of $10.00 per film per copy. Medical records are 25 for the first 25 pages and $2.50 .50/per page per copythereafter. These charges fees are not covered by your insurance and all requests should must be made in writing. Disability — Disability/FMLA forms or work forms that need needing to be completed by our office Obstetrics & Gynecology of North Texas will incur a charge of $10.00 25 per form per occurrence. — Minor Patients if unaccompanied non-emergency treatment will patients must be denied unless appropriate accompanied by a parent/legal guardian with a signed consent has been received and charges have been pre-authorizedform.