Please note: this form is not for on-line submission. Please print this page and bring this to the office for your visit.

James K. Baker, M.D.

Lone Star Orthopedics, PA

Financial policy form

This is an agreement between Lone Star Orthopedics, P.A., as creditor, and the Patient/Debtor named on this form.

 

In this agreement the words "you", "your", and "yours" means the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we", "us", and "our" refer to Lone Star Orthopedics, P.A. By singing this document, you also agree to our Financial Policy, page 2 form.

By executing this agreement, you are agreeing to pay for all services that are received.

Monthly Statement:  If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to your account, and any payments or credits applied to your account during the month.

 

Payments:  Unless we approve other arrangements in writing, the balance on your statement is due and payable when the statement is due and payable when the statement is issued, and is past due if not paid by the end of the month.

 

Charges to Account:   We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

Payment options if you have insurance:

1. You can choose to pay your deductible and any out-of-pocket portions at the time services are rendered by cash, check, or credit card.

2. Any co-payments must be collected before seeing physicians. This is required by your plan.

3. You can choose to pay all of your treatment by cash, check, or credit card. We will file your claim and request your insurance carrier send their payment directly to you.

Payment options if you have no insurance:

1. You can choose to pay by cash, check, or credit card on the day that treatment is rendered.

2. On extensive treatment, you may prefer to secure a bank, credit union, or other third-party financing for the entire amount and make payments to the lending institution.

Patient's name__________________________     Person responsible for payment (if not the patient)______________________________

Signature______________________________     Date_________________

Co-Signature (if required)______________________________     Date_________________