We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill when the services are rendered. We require that arrangements for payment of your estimated share be made today. If your insurance carrier does not remit payment within 60 days, the balance will be due in full. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining.
If any payment is made directly to you for services billed by us, you recognize an obligation to promptly submit the same to Orthopedic Rehabilitation and Specialty Center.
The above may not apply to those patients that are considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you.
When you pay by check, you expressly authorize Orthopedic Rehabilitation and Specialty Center, if your check is dishonored or returned for any reason, to electronically debit your account for the amount of the check plus a processing fee of up to the state maximum legal limit (plus any applicable sales tax). Please note: the above language authorizes an electronic debit to your account for the state-allowed recovery fee. In accordance with the rules of the National Automated Clearing House Association, you may call (888) 235-4635 to revoke the authorization for the electronic transaction. This does not, however, mean that OR&SC cannot collect a returned check fee by the other methods.
I understand and agree that if I fail to make any of the payments for which I am
responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.
Information Privacy: OR&SC will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care
operations. Health care operations generally include those activities we perform to
improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY
PRACTICES to help you better understand our policies in regard to your personal health information. The terms of the notice may change with time and we will always post the current notice at our facilities with copies for distribution. The undersigned acknowledges receipt of this information.
I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT.