Patient Annual Update Form

Demographic Information

Pharmacy

Primary Care Information

Insurance Information

Medical/Social Health Information

Triangle Foot and Ankle Specialist strive to render excellent medical care to you and to the rest of our patients.

OUR POLICIES ARE AS FOLLOWS

• A demographic information update is required at the beginning of every year. Please have your insurance information and photo identification readily available at the time of check in, to allow us to process your demographic information update in a timely manner.

1. PAYMENTS:

• When verifying benefits, it is never a guarantee of payment per your insurance company's disclaimer. You are responsible for all co-pays, deductibles, co-insurance amounts and non-covered services. ThePatient/Guardian is aware that their insurance company may not make payment on a claim and that it will be the Patient's/Guardian’s responsibility to do so.
• Your visits will be coded based on documentation from your provider during the visit, which may not be covered by your insurance carrier at 100%. Diagnosis codes will not be changed in an attempt to reduce out of pocket expenses.
• We do not go back and submit claims to patient’s insurance companies if at time of visit they had requested to be self-pay or if at the time of visit their insurance company states the service/product is non-covered.
  

2. CO-PAYS, CO-INSURANCE and DEDUCTIBLES:

• All Co-Pays, Deductibles, Co-insurance and any additional charges will be collected at the time of your visit.You are ultimately responsible for all payment of charges for services from our office.
• Account balances must be paid in full at the time of today’s appointment prior to seeing the doctor.
• It is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit.
• If your plan requires a referral, it is your responsibility to obtain this prior to being seen.
• If procedures are done in the office that are deemed non-covered by your insurance company, you will be responsible for the payment.
• Unpaid previous balances must be paid in full prior to scheduling additional visits, unless arrangement shave been made with the billing office.
• Returned check fee is $35.00, the balance and all future visits to our office must be paid via credit card or cash. We will no longer accept checks if there has ever been a returned check to our office for insufficient funds.
• The Patient will be responsible for all Attorney Fees, Legal Fees and Court Cost if the account is turned over to collections.
• A 35% Administration fee will be automatically added to all patients that are submitted to collections.
• If the Patient is a minor the Patient's Legal Guardian will be responsible for all Attorney Fees,Legal Fees and Court Cost if the account is turned over to collections.

3. DURABLE MEDICAL EQUIPMENT:

• If you have received a DME (Durable Medical Equipment) product (Ex: L1902, L1906, L4396, L2116) code in the last 5 years anywhere else and one is dispensed to you from our office it is the patient’s responsibility to alert us to this prior to dispensing. Some insurance only cover these codes once every 5 years and if we are not made aware it will not be covered by your insurance and the patient will be made responsible for the self-pay price of the device.

4. CANCELLATIONS:

• When an appointment is scheduled, that time has been set-aside for you and when it is missed, that time cannot be used to treat another patient.
• Cancellations for appointments and procedures must be received 24 hours prior to the scheduled appointment. You may leave a cancellation message on the answering machine.
• Patients who fail to keep or cancel a scheduled appointment will be charged a $50.00 NoShow/No-Call Fee. (We make reminder calls as a courtesy, but it is your responsibility to keep track of your appointment).
• Repeat failure to keep your scheduled appointments may force us to have your medical care transferred elsewhere.
• If a patient has two consecutive No-Show/No-Call fees, the balance of $100 must be collected via credit card prior to scheduling another appointment in our office.
• If a patient is late on the day of an appointment, the office will do everything possible to see the patient in a timely manner. If the patient decides to not keep that day’s appointment or reschedule the appointment a $50.00 fee will be applied to the patient chart for the missed appointment.
• A $250.00 deposit is required at time of scheduling a surgery. Once all your insurance claims have processed and your account has been paid in full and if you are due a refund, one will be issued to you upon request.
• Patients who fail to keep or cancel a scheduled surgery less than 30 days before the scheduled surgery will not be refunded the $250.00 surgery deposit, regardless of when the surgery was scheduled.

5. MEDICAL RECORDS:

• Medical Records request must be received at least 48 hours prior to the date needed.
• There is a non-refundable fee of $25.00 for requested copies of medical records.
• There is an additional non-refundable fee of $25.00 for requested copies of medical X-rays.
• Fees for medical are set in accordance as defined by the State of North Carolina.
• WE DO NOT FAX MEDICAL RECORDS TO PATIENTS OR FAMILY.
  
• All fees and account balances must be paid prior to pick up of medical records.

6. REFUNDS: (Pertaining to Insurances Only)

• An insurance company has Ninety Days to process your claim. Even after the Ninety Days the insurance company may still be processing your claim.
• Once we have received confirmation and payment from your insurance company and the remaining balance on your account is paid in full, upon request a refund check will be issued within 30 days of request.

7. RETURNS:

• We do not accept returns or cancellations for any reason on custom orthotics, over the counter orthotic inserts or medical products that have been dispensed to you by the doctor in the office.
• We do not accept returns of diabetic shoes or diabetic inserts for any reason. (See Authorization for Payment and Warranty form if dispensed diabetic shoes)
• HIPAA and NC Health Regulations prohibit the return of previously dispensed products.

8. SUMMARY / STATEMENTS:

• Your summary may not be ready for you at the end of your visit, since our doctor must first chart your visit, which will be after he sees all of his patients for the day.
• Statements are mailed out the first week of the month.
• If you do not have a balance, you will not receive a statement.

By signing you fully understand your rights and responsibilities.

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.