Office Policies

Please correct the errors described below.

Dear Patient:

Welcome to our office! We are pleased to have the opportunity to serve you and are dedicated to providing excellence in foot & ankle health care. We appreciate your comments and suggestions regarding our treatment, office procedures and staff. Please complete all forms, including signature at the end of this letter. We ask that these forms be filled out accurately and without omission in any section. This is a time-saver to you and to our office. Please bring all completed and signed forms with you to your appointment. Please arrive 10 minutes early for your appointment. Our policies are outlined below, so that you may become familiar with our office.

Insurance, Fees & Payments

If you have health insurance, please bring your insurance card with you for your scheduled appointment. In order to control costs, payment is expected at the time of your visit. Since most companies do not reimburse the total amount due, you will be responsible for any co-pays, deductibles and non-covered services. We will call to verify your coverage. Your insurance contract is made between you and your insurance company. As a courtesy, we file all insurance forms for you. If your insurance requires a referral from your primary care physician (PCP) to be seen by a specialist, please make sure we have a referral for you at our office. Without this referral, you will be expected to pay in full at the time of service. If you are unsure if you need a referral, please contact your insurance company to find out. We do not accept workers compensation or any other third party claims (e.g.: settlements, accident claims, attorneys, etc.) unless prior arrangements have been made with our business office. It is your responsibility to make our staff and physician aware of accident information. *Insurance NEVER guarantees payment of any service or item. Final determination is made when the claim is received and processed by your insurance.* *Self-pay patients will be expected to pay in full at the time of the appointment

For any surgery that you may need, we will call your insurance company to pre-certify these procedures. Please realize that precertification does not guarantee that your insurance company will pay.

Please be aware of the specific lab/facility you can use for your procedures or bloodwork under your insurance plan. It is ultimately the patient’s responsibility to know where your insurance plan is honored. The billing for procedures and blood work is billed from that lab/facility you use, with no affiliation with our office.

In fairness to other patients and the doctor, we require at least 24 hours’ notice to cancel appointments. In signing the bottom of this page, you agree to pay BRIGHT FOOT CLINIC your deductible amount, co-pay amount, charges approved by Medicare and any charges that your insurance allows and does not pay as well as any fees over and above that insurance does not pay. Also, in signing the bottom of this page, if you do not have insurance, you agree to pay BRIGHT FOOT CLINIC the full amount in proposed fees the date of service.

Due to an increased number of requests to file disability claims, FMLA claims, etc., we will now charge a prepayment fee of $25.00 for any form that is not routine insurance filing. Please allow five days for forms to be filled out.

*A photocopy of this assignment shall be considered as effective and valid as the original*

During the course of your physician/patient relationship with Dr. Dean E. Bright D.P.M., he may at a future time refer you to Northwest Health Physicians Specialty Hospital located at 3873 N. Parkview Drive, Fayetteville, AR 72703 of SurgCenter of Fayetteville located at 1905 E. Mission Blvd., Suite 5, Fayetteville, AR 72703. In connection with any such referral, Dr. Dean E. Bright, D.P.M. herby advises you that he has a partial ownership interest in the facilities. Please be advised that you have the right to obtain the health care services at any location from any ambulatory surgery center or hospital of your choice, including Northwest Health Physicians Specialty Hospital and SurgCenter of Fayetteville.

If you have any questions, please feel free to ask one of our office staff or call us at (479) 750-3131. We look forward to providing you with our best medical care.


Dean E. Bright, D.P.M. and Staff

How will you be paying for today’s visit?

Credit/Debit/HAS cards will incur a 2% surcharge.

I, the undersigned, state by my signature below that I have read and understand the above policies. I hereby authorize the release of any medical information necessary to process my benefit claims, authorize payment of medical benefits to the provider when applicable, and authorize the release of any medical information deemed necessary to my referring physician.

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

Your information will be encrypted.