OUR FINANCIAL POLICY
Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require you to sign prior to any treatment.
All patients must complete our information packet and produce all insurance cards and id prior to seeing the doctor
CUSTOM MADE PRODUCTS (SHOES, INSERTS, ORTHOTICS, ETC.) ARE NON REFUNDABLE.
24 Hours notice is required in the event you cannot keep your appointment. If notice is not given in a timely manner there is a mandatory $50.00 no show fee.
ALL returned checks have a $25.00 processing fee applied to the account.
Non insurance patients (self pay) full payment is due at time of service. We accept cash, check, credit card, etc.
We may accept assignment of insurance benefits. ALL co pays, coinsurance and deductibles are due at the time of service. In the event that your insurance is not in network you will be considered self pay. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a third party to that contract. Please be aware that some, perhaps all, of the services provided may be non covered services and not considered reasonable under your insurance program.
Usual and customary rates
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
Adult patients are responsible for their portion of payment at the time of service depending of self pay or insurance coverage.
The accompanying parent or guardian is responsible for full payment. For non accompanying minors, non emergency treatment will be denied.
Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read the financial policy. I understand and agree to this financial policy:
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.