Office Policies Consent

Step Alive Foot & Ankle Center, Dr. Thomas F. Vail Payment & Office Policy

Thank you for choosing Step Alive Foot & Ankle Center as your foot care provider. We are committed to providing you with quality and affordable health care.

Please read the following office payment policy and feel free to ask us any questions that you may have. Once you accept this policy, kindly sign in the space provided. A copy will be provided to you upon request.

1. Insurance

We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with, but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Each policy has different deductibles, co-pays, and co-insurance responsibility of the participant. Therefore, we encourage you to check your policy’s specific requirements for pre-certification for various treatments that may be planned for specific care. This may include, but not be limited to, MRI, bone scans, and physical therapy. We will continue to pre-certify surgeries and pre-certify as well as check into orthotics coverage as needed. However, a quote of benefit coverage is not a guarantee of payment. This office is not responsible for services rendered and not covered. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-Payments and Deductibles

All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. Deductibles are due immediately when insurance deems patient responsible. We reserve the right to ask for payment on deductibles not met before certain treatments and surgeries.

3. Non-Covered Services

Please be aware that some – and perhaps all – of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit. Medicare does not cover routine foot care; this includes the trimming of nails and cutting of calluses. If you are a diabetic or have peripheral vascular disease or painful nails, Medicare may pay for cutting of fungus nails. Medicare has other requirements such as timely appointment with your primary care physician or your specialist who manages your diabetes or peripheral vascular disease in order for these services to be covered. This would be your responsibility to supply those dates of service at your visit for your foot care. You also must be seen within the past 6 months by your primary care physician.

4. Proof of Insurance

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral form from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full. This payment will be held for 48 hours and will become non refundable if the proper referral is not obtained by then.

5. Claims Submission

We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claims. Your insurance benefit is a contract between you and your insurance company.

6. Coverage Changes

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. In-Office Supplies

Our office supplies as a convenience to our patients over-the-counter supplies. This is an effort to eliminate going to the store to pick these items up. In order to stock these supplies, we require payment at the time of service. Insurance companies do not cover the cost of these supplies; therefore you are responsible. The office assistant will discuss a fee for the item prior to your departure. If you are unable to pay for the item at the time of service, then we kindly request you return to pick up the item when you are able to afford it.

8. Nonpayment

Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. A rebilling charge of $10.00 per month will accrue on all accounts 30 days past due and over. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to collections with an additional charge added to cover the cost of the collection agency service fee. If this occurs you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Any checks returned with insufficient funds will be charged a processing fee.

9. Missed Appointments

Our policy is to charge for missed appointments not cancelled at least 24 business hours prior to the appointment time unless waived for an understandable reason. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

Our fees are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I hereby give my permission for Dr. T.F. Vail, DPM to examine my feet medically or orthopedically. I authorize release of any information pertaining to my medical treatment. The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claims.

to pay and hereby assign directly to Dr. Thomas F. Vail (Name of Provider)

all benefits, if any, otherwise payable to me for his/her services as described on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits when received by and paid to Dr. Thomas F. Vail will be credited to my account, in accordance with the above said assignment.

I have read and understand the payment policy and agree to abide by its guidelines:

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 form.