Patient Easy Pay Policy and Consent

We will submit charges for your medical care directly to your insurer if we have a contract with that company.

All co-pays are due before your visit with the doctor. All over-the-counter products purchased thru the clinic are due upon check-out at your visit.

Please be aware that balances deemed patient responsible, either due to deductible, co-insurance or a non-covered service, may become due prior to your next follow-up visit. We accept for your convenience MasterCard, Visa, and Discover.

In order to continually give the highest quality healthcare we ask that any balance remaining on charges after your insurance company pays their portion be charged to your credit card/or health savings card. As a courtesy, we will call you before processing any charges on your credit card above $50.00. The information will be kept secure and confidential. You will receive a receipt via e-mail for any charges on your credit card or health savings card.

If you have a Health Savings Credit Card (HSA) we do require you to check the first box below and enter your card information.

I authorize Dr. Thomas Vail and the Step Alive Foot & Ankle Center to charge my credit card or health savings card for any balance remaining on my account that insurance has deemed my responsibility. I will be notified before processing of charges over $50.00.

Patient Name

Cardholder Name

Credit Card Number

Zip Code

MasterCard

Visa

Discover

Expiration Date

3 Digit Security Code

Card Holder Signature

Date

I choose not to do 'Easy Pay' and understand that charges that are deemed my responsibility by my insurance company will need to be paid IN FULL prior to any follow-up visits with the doctor even if I have not received a statement in the mail. These balances will be asked for at check-in. Any balances not paid in full at check-in are subject to a $10.00 rebilling fee on your monthly statement.

*I also authorize my healthcare provider and/or any entity authorized by my healthcare provider, including those using automated dialing systems, automated messages, email, text messaging or other electronic communication to contact me for any reason by using any telephone number, email address and/or mailing address provided.

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.

Electronic Signature

Date

Your information will be encrypted.