Financial Policy Form

Financial Policy For Purvis-Moyer Foot & Ankle Center (PMFAC)

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Providing foot and ankle care for the entire family in a caring and friendly atmosphere

Insurance

If you are not insured by a plan we are contracted with, payment in full is required at each visit. If you do not have a current insurance card, payment in full is required at each visit. We will not file any services to your insurance company that were charged prior to insurance verification. Knowing your insurance benefits is your responsibility. If you have any questions regarding your coverage you will need to contact your insurance company directly. Please be aware that all services may not be covered by your insurance company and you will be responsible for payment if you elect to have the services provided.

Medicare

We will file your claim to Medicare and any secondary policy if applicable. You are responsible to pay any of your annual deductible that may not have been met, plus your 20% coinsurance at the time services are provided. Please be aware that not all services are covered by Medicare and you will be responsible for payment if you elect to have the services provided.

Secondary/Tertiary Insurance

As a courtesy, we will file your secondary and tertiary insurance claim one time at no charge.

Co-payments and Deductibles

All co-payments and/or deductibles are due at the time services are rendered. As part of our contract with your carrier it is our responsibility to collect at the time services are rendered. Please be aware of your benefits. All overdue accounts will assess finance charges at 18% interest each month. Any account balance unpaid beyond 90 days will be forwarded to an outside service and additional fees will apply.

Self-Pay

All self-pay/uninsured patients are required to pay in full prior to services being rendered. We will provide you an estimated fee based on the foot condition you are being seen for.

Refunds

Any refund check needing to be reissued will incur a $25 processing fee.

Referrals/Authorizations

As part of our contract, we are required to follow guidelines set by the insurance companies. If your policy requires a referral/authorization, it is your responsibility to make sure that it has been provided to our office or you have a written authorization at the time of your appointment. If you do not have at the time of your visit you will be considered a self-pay patient and payment will be required in full or you will have the option to reschedule the appointment once you have obtained the necessary information. We will not call your Primary Care Physician or hold your appointment time for you to call.

Medicaid

All Medicaid co-pays are due prior to being seen. It is your responsibility to obtain your appointment through your Primary Care Physician. It is not our office’s responsibility to call and obtain this information. You will have the option to be a self-pay patient or reschedule through the proper process. We will NOT call nor will we hold your appointment for you to call once your scheduled time has passed.

Insurance Claim Filing

We will submit your claims and assist you in any way we reasonably can. Your insurance may require information from you to process your claim. It is your responsibility to provide any information requested. Please be aware that the balance of your claim is your responsibility for any balance past 90 days. Your insurance benefit is a contract between you and your carrier.

Workers Compensation Claims

Any claims being filed as a worker’s compensation claim must be stated at the initial phone call. All necessary paperwork must be completed and approved prior to your appointment.

No Show/Cancellation Policy

If you do not keep the dedicated appointment time held for you or you cancel your appointment less than 24 hours you will be charged a $25 fee. This will have to be paid prior to any additional appointments being scheduled for you.

Dependent Children

The responsibility for payment for services rendered to any dependent children whose parents are divorced rests with the parent who seeks treatment. Any court-ordered responsibility judgment must be determined between the individuals involved with the exclusion of our office.

Patient Billing

Our office will send up to three (3) notices for your financial responsibility after payment and/or explanation of benefits is received from your insurance company(ies). After the last notice, your outstanding account may be forwarded to an outside agency along with any service fees for collection. Payment arrangements can be made on a case by case basis. We accept cash, checks, Visa, Mastercard, Discover and CareCredit. There is a $30 returned/stop payment fee.

Records Request/Disability Forms

Any requests for medical records ($20) or x-rays ($10 ) must be accompanied with a signed authorization to release information. Payment is due at the time of request. Once a request has been made, you must allow 7 days to complete. You may access the patient portal at any time.

Discharge From Practice

You may be discharged from PMFAC for non-payment, non-compliance or unacceptable behavior with the staff.

I have read the above policy regarding my financial responsibility to Purvis-Moyer Foot & Ankle Center for medical services provided. I agree to pay PMFAC any balance unpaid by my insurance carrier.

Assignment of Benefits

I, the undersigned, certify that I (or my dependent) have coverage with my insurance company presented and assign all benefits directly to PMFAC. I understand that I am responsible for payment of deductibles, co-payments, co-insurance and/or non-covered services. I hereby authorize the doctor to release all information necessary to obtain payment of benefits. I authorize Release of Medical Information to my insurance carrier or requested physician to provide continuity of care.

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.

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