Financial Policy

We are glad you have chosen.our office to help you in your health care. The doctors and staff strive to prescribe the best up to date treatments possible,

Full payment is expected on the day medical services are provided unless you have health Insurance coverage with a plan that we have a written agreement. Our financial policy offers you a number of payment options such as: cash, checks, and Visa and MasterCard. Patients with Insurance must pay, when applicable: Deductible an amount you must pay first out of your own pocket each year before insurance will pay for any services. Co-payment- an amount you must pay upon each visit to a doctor that is due at the time of service; Co-insurance, an amount which usually is a percentage of the fee that, your insurance company will not pay. Deductibles, co payment, and co insurance are patient responsibility. On treatments that Involve items chat are non-covered by, Insurance, or custom order Items, you will be required to pay 50% down at the time of visit, and the remaining balance when the product ls dispensed. Orthotics require a deposit of $100.00 at the time of casting, and miscellaneous supples are to be paid upon dispense.

We will need to make a copy of the front and back of your Insurance card at your initial visit. Existing patients are to Inform us of any changes In coverage that may have occurred since your last visit and provide us with insurance card coples at that time. If you have two or more Insurance polices, it is your responsibllity to inform us which pollcy is Primary (first) coverage, which pollcy is Secondary (second) coverage, and which pollcy is Tertiary (third) coverage. With each policy we will require the name, date of birth, address, phone number, and employer of the member who carrles the policy.

Billing Statement: If you have a balance on your account, you will be sent a monthly billing statement. We do not send Invoices but rather billing statements in the middle of each month. 

Payments: Unless other arrangements are approved by us in writing, the balance on your billing statement is due and payable by the last business day of the month the billing statement is issued.

Charges to Account: We have the right to cancel your privilege to make charges agalnst your account at any time. If the patent's account Is In a past due status, services must be pald in full prior to any services belng rendered. Charges for services will continue to be pald In advance until the past due balance is pald In full by guaranteed payment methods, such as, Cash, Cashier's Check, or Debit Card.

Past Due Account Balances: If your account becomes past due, we may refer the overdue balance to a collection agency or to an attorney. I acknowledge and agree to pay all collection costs, attorney fees, and all court costs.

No Show Fee: A no show fee of $50.00 will be added to your account after 3 consecutively missed appointments. We require you to provide 24 hour notice of cancellation in order to walve the No Show Fee.

Returned Checks: A $35.00 fee will be charged for any checks returned by the bank.

Telephone Contact: I give my permission to Associated Podiatrists, LP, and Its Affiliates or contractors to contact me for any purpose at the current or an future numbers that are provided for my land line telephone, cellular telephone or any wireless device Including the use of automated diallng equipment, prerecorded voice, or text messages.

Preferred Provider Agreement Insurances: If we are Preferred Providers with your insurance company, we must follow. our signed agreement. If you have a co-payment you must pay that at the time of service. It is the Insurance company's requirement to make the final determination of your eligibility, Some insurance plans require a referral and/or preauthorization from your primary care physician. You are responsible for obtaining the referral and/or preauthorization prior to your appolntment or full payment will be expected for the medical services rendered.

Non-Preferred Provider Agreement Insurances: If we are not Preferred Providers with your insurance company, we will bill your insurance company as a courtesy to you. By signing this Polly, you acknowledge and agree to pay any portion of the charges not covered by Insurance. Fallure to obtain the necessary referral and/or preauthorization is your responsibility prior to your appointment. Failure to obtain the necessary referral and/or preauthorization may result In lower payment from the Insurance company, and/or denial of charges. Payment of these deled services will be expected to be paid in full.

Workers Compensation: We require written approval/authorization by your employer and/or worker's compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Marital Separation: If a couple is separated, but remain legally married, both partles are equally financially liable. If a minor child is the patient, both parties are equally financially llable,

Divorce: In case of divorce, the party, or parties responsible for charges incurred on the account prior to the divorce remains responsible for the account. If a minor child ls treated, elther pre or post divorce, both parents are Jointly and severally responsible for any balances due.

Transferring Records: You will need to provide a completed Associated Podlatrists Medical Record Form if you want to have coples of your records sent to another doctor or organization. The amount charged per page is $.25. You authorize us to include all relevant information, Including your payment history. If you are requesting your records to batransferred from anther doctor or organization to us, you authorize. us to recalve allrelevant Information, including your payment history. X-ray coples are available to be transferred to another physician. Copies for x-rays are $10.00 per sheet. We request that you please provide at least 3 days notice, prior to needine copies of your records.

Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, payment of the bill remains the patient's responsibility, Even if a personal injury claim or lawsuit is pending. See the paragraph that refers to Non- Preferred Provider Insurances above.

By signing this document I acknowledge and agree to this entire Financial Policy

Please feel free to ask any questions regarding your Insurance and treatment in our office and we will do our best to assist you,

Thank you.
ASSOCIATED PODIATRISTS, ULP