Important Office Information
Welcome to Advanced Foot and Ankle Centers. We are committed to providing you with the best care possible. Your understating of our Office Policy is very important to us. Please read the following information, sign and return it to us. We will be happy to discuss any questions that you may have.
INSURANCE AND CLAIM SUBMISSION: We participate with many various insurance companies. As a courtesy, we will bill most insurance companies for our patients. Please understand that your insurance coverage is an agreement between you and your insurance company. Knowing your insurance benefits is
PROOF OF INSURANCE: All patients are required to compete and/or update our patient information form. You will be asked to verify your address, phone and insurance information. If you cannot provide up-to-date health insurance information, you will be responsible for payment in full.
CO-PAYS AND DEDUCTIBLES: Co-pays and deductibles are the out of pocket expenses you are responsible for. Co-pays are required for all office visits, including follow-up examinations. Deductibles are determined by your policy with your insurance carrier. We collect office visit co-pays on the day of your visit. We can’t write off co-pays and deductibles because we have signed a contract with the insurance carrier that stipulates we collect co-pays and deductibles from the patient
YOUR ACCOUNT: Statements are billed monthly. Payment Plans are available based on balance and account history. Accounts that are 90 days past due with no payment history will be turned over to a collection agency. Personal checks that are returned for non-sufficient funds are subject to a $25.00 administrative fee.
MISSED APPOINTMENTS: There will be a $25.00 fee charged to your account if you do not give 24 hours advance notice. If you are more that 15 minutes late, without notification, your appointment will be changed to a no show and you will be rescheduled. After 3 no show appointments you will be discharged from the practice.
FORMS: There is charge for the physician to fill out forms. Two pages or less is $10.00. Three pages or more is $25.00. This is due at the time the form is picked up.
I have read and understand the office policy and agree to abide by its guidelines.
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.