Thank you for choosing our office for your foot & ankle health care needs. We are committed to your treatment being successful. Please understand that payment of your account is considered part of your treatment. If you have any questions regarding our financial policy, please contact our main office at 970-259-5303.
Charges for medical services are due and payable at the time services are rendered. Charges for medical care provided by this medical practice will be billed through our office and should not be confused with charges for medical care provided by the hospital. We accept Visa, MasterCard, Discover, American Express, and Care Credit as well as personal checks, money orders and cash. Once products are taken from our facility, i.e, braces, orthotics, splints, etc., they cannot be returned or refunded
*In accordance with guidelines set forth by the state of Colorado & New Mexico State Board of Medical Examiners, if further action must be taken on my account, I may be discharged from this practice and be required to seek further care elsewhere.
Contracted Insurance: If we are contracted with your insurance company you will be responsible for your co-pay, coinsurance, deductible, and any non-covered items/supplies due at the time of service. Any balance remaining after the insurance payment is made is due to our office within 30-days.
Non-contracted Insurance: Patients who have policies with non-contracted insurance companies will be responsible for payment in full for all office visits/procedures at the time service is rendered. We will bill your insurance company and you will be reimbursed directly
Home Health Agencies / Nursing Home Rehab Centers: Our office requires that if a patient is in one of these facilities and cannot provide health information themselves, they must have a family member accompany the patient so they can help the patient fill out new patient paperwork, provide copies of insurance cards, state issued identification card or driver license and medical history
Self-Pay Patients: We offer a 30% discount of services rendered except for supplies. We make no long-term payment arrangements on patient balances.
*Returned Check Fee: We will apply a $30.00 (thirty dollars), plus any additional charges allowed by CRS 13-1-109 for any returned check. All payments thereafter must be made with cash or debit/credit card.
*Outside Services: I understand that certain services may be sent to an outside source such as lab, pathology, and diagnostic services and thus will be billed separately for those services.
*Cancelled & No Call / No Show Appointments: Our office offers appointment reminders and as such we require that you give a 24-hour notice if you need to cancel your appointment for whatever reason. You will only be allowed 3 failed visits then Four Corners Foot & Ankle has the right to discharge you from care at the discretion of their doctors.
I understand that if, 45 days after billing my insurance they have not paid, my account will be due and payable by me. In the event my account becomes past due, my balance will accrue interest at the rate of 18 % per month. In addition, I will be responsible for collection costs, attorney fees, court costs, and any other miscellaneous fees. I consent to have the collection agency obtain my credit report for the purposes of collection on my account