Section 3: Financial Policy

Foot & Ankle Center of Lake City

Please correct the errors described below.

FINANCIAL POLICY

Effective June 20, 2017

Thank you for choosing our office for your podiatric needs. We are committed to your treatment being successful, as you, the patient, are our first and foremost concern. Your clear understanding of our Financial Policy is important to our professional relationship and as part of our service we try to contain the cost of health care. To avoid any misunderstandings, please feel free to ask us any questions about our policies.

Insurance

Dr. Berg is contracted with most insurance plans. Your insurance policy is a contract between you and your insurance company. It is your responsibility to contact your insurance company regarding pre-authorizations. obtaining required referrals and second opinions.

Insurance Deductibles

All deductible balances are due within 14 days of receipt of patient statement. In certain cases, where there is a large deductible balance, we ma be able to arrange a payment program of automatic deduction on a credit card.

Co-Payments

Please be prepared to pay all co-pays at the time of service.

Patient Balances

All remaining patient balances, are due by the end of the month in which you receive your statement. If you need more time to pay your balance we can arrange for you to apply for CARE CREDIT. Please ask at the front desk for an application. A $12.00 rebilling fee will be added to each statement sent for an unpaid balance. Past due accounts, more than 90 days. will be sent to our collection agency and a fe of up to 35% of the balance due will be added to cover collection costs.

Cancellation and Rescheduling

A 24-Hour notice is expected for cancellations and/or rescheduling of appointments. We will try to accommodate you in rescheduling your appointment as soon as possible. Cancellations without 24 hour notice and No-Shows will result in a $75 Missed Appointment Fee.

This fee must be paid before your next appointment

No Insurance

If you do not have insurance, please be prepared to fully cover the fees for each visit at time of treatment.

Secondary Insurance

If you have secondary insurance, we will bill them one time. If your secondary insurance does not pay the balance within 45 days, that balance will be billed to you and due at that time.

Minor Patients

The adult or parent (custodial guardian) accompanying a minor is responsible for payment of services. Young adult (age 18 or over) are legally responsible for their accounts unless a parent accompanies them to the initial appointment and signs this financial agreement, regardless of insurance coverage.

Supplies

To provide the best possible treatment plan for you, our doctor offers every level of podiatric care. Often, the use of a foot care product is an appropriate treatment for a successful outcome. For your convenience, we make some supplies available for purchase through R&M Medical and Supply . R&M Medical and Supply is located here in our office but is not contracted with any insurance companies, so payment is due at time of sale. Our doctor is happy to offer a prescription for a comparable product if you would prefer to obtain the supplies through your pharmacy.

Agreement

I have read and agree to the terms set forth in the above financial policy. I also understand that I am financially responsible for any treatment rendered to me or minor child by Foot & Ankle Center of Lake City. I, therefore, authorize Foot & Ankle Center of Lake City to release and or exchange medical records, billing and collection information for the purpose of obtaining payment for services rendered.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Financial Responsible Party:

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