Financial policy form,page 2
James K. Baker, M.D.
Lone Star Orthopedics, PA
Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.
Returned checks: There is a $25.00 fee for any check returned by the bank.
Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer our account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to an attorney, you agree to pay all attorney's fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Hays County, Texas.
Waiver of Confidentiality: You understand if this acount is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.
Transferring of records: You will need to request in writing, and pay a copying and handling fee, minimum $15, if you want to have copies of your records sent to another doctor or organization. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.
Worker's Compensation: We require approval/authorization by your employer and/or carrier prior to your initial visit. If your claim is denied, you will be responsible for your payment in full.
Co-Signature: If this or another Financial Policy is signed by another person, that co-signature remains in effect until canceled in writing. If written cancellation is received, it becomes effective with any subsequent charges.
Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein, and the agreement will be in full force and effect.