PATIENT FINANCIAL POLICY

This is an agreement between Boise Orthopedic Clinic and the Patient/Guarantor named below.  By signing this agreement, you are acknowledging that you understand our insurance and financial policies and are agreeing to pay for all services that are received.

Initial Visit

Please provide us with your insurance card and billing information if you would like us to bill your insurance for you.  Otherwise, payment in full will be required at the time of your visit.

Health Insurance & Workers Compensation

We will bill your insurance company as a courtesy to you.  Each insurance company has its own rules for determining how much they will pay on each claim.  We will try to answer any questions you have about your insurance; however, your policy is a contract between you and your insurance company.  It is your responsibility to know your insurance policy and be familiar with your coverage.  You should contact your insurance company immediately if you have questions regarding coverage or payment of your claims.  We do not accept assignment on out-of-state worker’s compensation claims and we will require that you pay for any charges not covered by insurance on out-of-state claims. If your insurance company denies your claim, including worker’s compensation, you are responsible for payment in full.

Personal Injury, Auto and Third Party

We require payment at time of service.  We do not bill liability insurance carriers or your attorney for charges incurred due to personal injury cases.

Medicare

We participate with Original Medicare and some Part C Plans including True Blue.  If you have a Part C Private Fee-for-Service (Medicare Advantage) Plan we will expect that the terms, coverage and payment schedule will be no less than Original Medicare.  Your Part C Private Fee-for-Service Plan is a contract between you and your insurer. 
It is your responsibility to know which procedures may require preauthorization or a second opinion.  If your Private Part C Medicare Plan denies your claim or reduces payment for services we provide to you, you are responsible for payment equal to what Original Medicare will allow for the service.

Medicare limits payment for physical and speech therapy to a combined cap of $1,810 per year.  You will receive a notice from Medicare advising you of the dollar amount that has been applied during the calendar year towards the cap. You are responsible for payment of any physical therapy services we provide to you that exceed your annual Medicare benefit.

Surgery Estimate and Prepayment

If you require surgery, as part of the pre-operative process we will make an estimate of the fees. The actual charges billed for your surgery will reflect the procedures performed and may differ from the estimate. Prepayment is due at your final pre-operative appointment as follows:

• Health Insurance Plans:  unmet deductible and    estimated co-pay
• Self-Pay:  one-third of estimated fees

Payments & Late Charges

Unless we approve other arrangements in writing, the balance on your statement is due upon receipt.  If payment is not received, we reserve the right to refuse future appointments on delinquent accounts.  If your account becomes past due, we will take necessary steps to collect this debt. All unpaid accounts for which payment arrangements have not been made are subject to collection procedures and additional collection costs. We add late charges to balances that are over 90 days past due at the rate of 1.5% per month, 18% annually. 

Payment Options

• You may pay by cash, check or credit card or CareCredit
• Three equal payments within 90 days from the date of service without late charges
• Payment plans extending beyond 90 days must be agreed to in writing by this office and may be subject to a payment plan setup fee. Unpaid, delinquent balances are subject to collection procedures and additional collection costs.

I have read, understand and agree to comply with these policies.
 I acknowledge receipt of Boise Orthopedic Clinic’s Notice of Privacy Practices.

 

Date:                                                         Signature:X                                                                        
                                                                                          SIGNATURE OF PATIENT/RESPONSIBLE PARTY

                                                                                            
                      PRINT NAME OF PATIENT