• Patient Demographics Form

    • PATIENT INFORMATION  
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    • PATIENT INSURANCE INFORMATION  

    • Patient Insurance Plan(s)

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    • OPTIONAL RELEASE OF INFORMATION  

    • Patient Health Information- Optional Release

      Patient health information is considered private and under protection by law. However, you may authorize chosen individuals to disclose information, retrieve documents, or discuss your health on your behalf. Please list authorized individuals below.
    • ACKNOWLEDGEMENT OF PRIVACY PRACTICES  

    • By signing below, I acknowledge the following statements:

      I understand the Health Insurance Portability & Accountability Act of 1996 (HIPAA) grants me certain rights to the privacy of my protected health information. I understand my healthcare information may be used or disclosed for treatment, payment, healthcare operations, or as required by law. I acknowledge that Academy Orthopedics, LLC has a Notice of Privacy Practices and I have the right to review or request a copy of this Notice prior to signing this agreement. I further understand I may request an additional copy of the Notice of Privacy Practices at any time in the future.

      I hereby authorize Academy Orthopedics, LLC to discuss my medical and/or billing information with the person(s) listed above. I understand that my information or records may include information regarding HIV, psychiatric and mental illness, drug/alcohol abuse records, venereal disease, and any other statutory protected diseases. I may revoke these privileges in writing at any time.

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  • PATIENT FINANCIAL POLICY

    Thank you for choosing Academy Orthopedics for your care. Our physicians and staff are committed to the success of your medical treatment. Our goal is to provide patients with excellent quality of medical care and exceptional customer service. Please review our financial policy listed below.

  • Insurance Patients: Patients must present valid health insurance along with a driver’s license or other form of ID at the time of service. All co-pays must be paid on the date of service. As a courtesy, we will file all qualifying insurance claims to the patient’s medical insurance after their visit. It is the patient’s responsibility to understand their own insurance plan and benefits; patients should contact their health insurance directly with questions related to their plan. After a patient’s insurance has submitted payment for a claim, any remaining balance will become the patient’s full responsibility and must be paid within (30) days of invoice. Please note, any claims found to be the result of a work-related injury or motor vehicle accident may not qualify to be filed with the patient’s regular health insurance plan.

    Self-Pay Patients: Self pay patients are required to pay in full at the time of service. Self-pay patients are responsible for the office visit fee plus any additional services performed during the appointment. These include, but are not limited to: x-rays, casts, splints, injections, etc. A self-pay price list is available at the front desk, and all self-pay patients will be informed of any additional charges prior to performance of a service.

    Workers’ Compensation: All charges for services incurred while treating a verified work-related injury will be billed to the patient’s workers’ compensation carrier. Claim information and authorization must be obtained prior to the start of treatment. If a claim is denied through the workers’ compensation carrier or later found not be the result of a work-related injury, the patient may have their claims filed with their personal medical insurance or become directly responsible for charges accrued. If a patient is treated for a condition that was never reported to their employer but found to be the result of a previous work-related injury, the claim will not qualify to be sent to a workers’ compensation carrier. Any denied claim, even those in litigation, will become the full financial responsibility of the patient.

    Motor Vehicle Accidents: Per company policy, we are unable to file claims related to a motor vehicle accident to a patient’s health or car insurance. If a patient’s condition is the result of a motor vehicle accident or collision, the patient will be financially responsible for any incurred charges. The patient will be treated as a self-pay patient, and payment will be due at time of service. If any claims submitted to a patient’s medical insurance are later found to be the result of a previous or unmentioned motor vehicle accident, the patient will become fully financially responsible for any denied or retracted claims.

    Missed Appointments: In the event of a cancellation, we require at least 24 hours’ notice prior to the scheduled appointment time. Patients not giving 24 hours’ notice will incur a $50.00 missed appointment fee.

    Missed/Cancelled Surgery: There will be a fee of 10% of the total charge of the surgery charged to the patient's account if 24 hours cancellation notice is not given for any surgical procedure scheduled.

    Form Fee: All disability, leave of absence (FMLA), etc., forms are generally completed within 7-14 business days after receipt. Pre-payment of $50.00 (cash, check, debit, or credit) per form must be paid prior to completion.

    Overdue Accounts: All overdue accounts will be sent to a collection agency and may be subject to legal action. Relevant personal and account information may be released during this action. If sent to collections, patient accounts will accrue an additional 38% charge in addition to any existing balance. 

    We accept cash, checks, Mastercard, Visa, Discover, American Express, and CareCredit. Additionally, patients may visit www.academyorthopedics.com to pay their account balance online.

  • I have read the above agreement and accept the terms in cooperation of Academy Orthopedics, LLC. I understand I will be fully financially responsible for any cost(s) associated with the collection of my account if I default on this agreement. I understand this financial agreement can be amended at any time without prior notification to me, the patient. In the event of the patient being a minor, I am the legal guardian or parent of the patient, and I agree that I am responsible for all services rendered to the patient herein.

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