Thank you for choosing Prairie-Rock Foot & Ankle Clinic. We believe good care for you and your family starts with good communication. We have developed this Financial Policy to help you understand your responsibility for payment of our fees.
The patient, or legal guardian of the patient if over the age of 18, is always responsible for payment. In consideration of services to be rendered, you, as the undersigned patient or guarantor, agree to pay Prairie-Rock Foot & Ankle Clinic for all services and supplies provided to you (or the patient) at the established rates, including any deductibles, co-payments, co-insurances, earlier charges that remain unpaid, or any other charges as permitted by third party payers. By signing this financial policy summary, you accept responsibility for any costs, including attorney or collection fees incurred by Prairie-Rock Foot & Ankle Clinic for the collection of charges for examinations, diagnosis, or treatment received. Prior to services being rendered you must furnish Prairie-Rock Foot & Ankle Clinic with accurate insurance information. For your convenience we accept cash, checks, and major credit cards.
Prairie-Rock Foot & Ankle Clinic requires payment in full prior to all services for patients who are uninsured. We may ask self-pay patients to place a credit/debit card on file for unpaid balances.
Prairie-Rock Foot and Ankle accepts Medicare assignment. For covered services, you are responsible for the deductibles and co-insurance amounts determined by Medicare. If you have supplemental insurance, we will bill the secondary carrier for you. If you do not have supplemental insurance the 20% co-insurance and/or any unmet deductible may be due at time of service. Once claims process, you will receive a statement for any outstanding patient responsibility. If Prairie-Rock Foot & Ankle Clinic believes that one or more of the services provided to you may be considered “non-covered” by Medicare, an Advanced Beneficiary Notice will be presented to you for signature and the associated fee may be due at time of service.
Please keep in mind, your insurance policy is a contract between you and your insurance company. You are ultimately responsible for all charges incurred. You must provide us with current and correct insurance information at every visit. Please notify Prairie-Rock Foot and Ankle immediately regarding any changes in insurance. All applicable co-payments are due at time of service. If you are unable to pay co-pay at time of service, your appointment may be rescheduled. If you do not agree with the patient responsibility set by your insurance, this is a matter between you and your insurer. We are happy to provide you with information needed to assist you in your discussion with the payer.
Prior to services being rendered, Prairie-Rock Foot & Ankle Clinic may conduct insurance verification and provide you with the estimated patient responsibility. Prairie-Rock Foot & Ankle Clinic may require you to pay a portion or all of the estimated patient responsibility prior to services being rendered. Because the insurance carrier can only provide us with an estimation of patient responsibility, there may be an additional patient balance due once the claim processes. You will receive a statement for any additional balance due. If claim processing results in a patient credit balance on your account, a review of your account will occur once treatment has been completed. Patient overpayments are then refunded within 4-6 weeks.
Accident-Related Injury:Prairie-Rock Foot & Ankle Clinic holds the person who has received our services responsible for the bill payment, regardless of any pending legal action. Injured patients under the age of 18 will have financial liability default to a parent or legal guardian. Prairie-Rock Foot & Ankle Clinic does not file claims to liability carriers unless the patient’s primary insurance is Medicare. We will file your claims to your personal health insurance, and you will be responsible for providing all involved insurance carriers with the required information needed for subrogation. We will gladly provide medical records as requested by your insurance carrier or legal counsel with a signed release. We have the right to collect unpaid plan deductibles, co-insurance, and co-pays as outlined in your benefit plan summary. If we do not receive payment from your health insurance in a timely manner, or your claims are denied, you will be billed for all remaining balances. Unpaid balances are eligible for collections and legal action.
Each visit and procedure will require written authorization from your Workers’ Compensation adjuster and/or insurance carrier.
The fee to complete form(s), such as FMLA, disability, etc., starts at $20 per form (may increase depending on complexity of form). A fee will be assessed each time a new form is completed.
The patient medical record is owned by the physician and facility in which the medical record was created. The information obtained in the medical record is owned by the patient. Therefore, all patients are entitled to receive a copy of their medical record. Upon request from the patient, or patient guardian, we will provide copies of the requested information. Prairie-Rock Foot & Ankle Clinic charges a fee for the copying of medical records in accordance with Illinois Law (Public Act 92-228).
Statements are mailed to patients every 35 days that have an outstanding patient balance due on their account. Payment is expected upon receipt of statement. If you are unable to pay your account balance in full, please contact our billing team immediately to take advantage of one of our payment options. All outstanding balances that are not on a scheduled payment plan may be referred to an outside collection agency.
In the event your account is referred to a collection agency for non-payment, Prairie-Rock Foot & Ankle Clinic shall be entitled to the right of recovery for all collection expenses, including court costs and reasonable attorney fees, incurred for the purpose of obtaining payment of the amount due. Because we offer various payment plan options, if your account is referred to a collection agency, we may require payment in full before allowing you to secure future appointments. If we are listed in a bankruptcy, we may ask for a cash deposit on any future services.
Returned check fee $25. This fee may be increased as needed
I have read the Prairie-Rock Foot & Ankle Clinic Financial Policy and agree to it. I hereby authorize Prairie-Rock Foot & Ankle Clinic to provide me with health care services and to furnish information to any health insurance carrier, workers’ compensation carrier, or attorney concerning my treatment. I understand that I am financially responsible for payment of all copayments, deductibles, co-insurance, and non-covered services as determined by my insurance plan.
I authorize payment of my health insurance benefits to Prairie-Rock Foot & Ankle Clinic for all services provided.
I expressly consent to be contacted, by Prairie-Rock Foot & Ankle Clinic or anyone calling on its behalf, for any and all purposes, at any telephone number, or physical or electronic address you provide or which you may be reached, including any wireless telephone number. I agree that Prairie-Rock Foot & Ankle Clinic may contact me in anyway, including calls or pre-recorded or artificial voice or text messages delivered by an automatic telephone dialing system, or email messages delivered by an automatic emailing system.
I expressly acknowledge that this consent cannot be revoked without prior agreement and acceptance by Prairie-Rock Foot & Ankle Clinic.
I agree to promptly notify Prairie-Rock Foot & Ankle Clinic at any time my contact information changes.
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.
Prairie-Rock Foot & Ankle Clinic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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