NOTICE OF FINANCIAL POLICY FOR LONE STAR ORTHOPEDICS, P.A. Back to Welcome
Effective Date: November 1, 2005
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THIS NOTICE DESCRIBES THE FINANCIAL POLICY THAT YOU AGREE TO WHEN YOU BECOME A PATIENT OF LONE STAR ORTHOPEDICS, P.A. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Patti Greeson, Office Manager at (512) 353-8658.
WHO MUST FOLLOW THIS NOTICE?
All patients of Lone Star Orthopedics, P.A.
TERMS:
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" mean 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.
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 the account, and any payments or credits applied to your account during the month..
PAYMENTS:
Unless we approve other arrangement in writing, the balance on your 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:
You can choose to pay your deductible of and any out-of-pocket portions at the time services are rendered by cash, check, or credit card. If you choose to use a credit card, we will collect an additional 3% of billed charges as a convenience fee to cover the cost of the credit card transaction.
Any co-payments must be collected before seeing the physician. This is required by your plan.
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 Do Not Have Insurance:
You can choose to pay by cash, check, or credit card on the day that treatment is rendered. Lone Star Orthopedics, P.A. accepts MasterCard and Visa charge cards.
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.
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 your 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/NSF CHECKS:
There is a $25 fee for any checks 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 your 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.
WAVER OF CONFIDENTIALITY:
You understand if this account 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.
REQUESTS FOR COPIES OF MEDICAL RECORDS:
You will need to request in writing, and pay a copying and handling fee 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.
The legal fee for furnishing copies of medical or billing records is established by Texas statute (Texas Administrative Code Title 22 Part 9 rule 165.2). A reasonable fee shall be a charge of no more than $25.00 for the first twenty pages, and 50¢ per page for every copy thereafter. If an affidavit is requested, certifying that the information is a true and correct copy of the records, a reasonable fee of up to $15.00 may be charged for executing the affidavit. A physician may charge separate fees for medical and billing records requested. The fee may not include costs associated with searching for and retrieving the requested information. A reasonable fee shall include only the costs of copying, postage, and preparation of a summary of the records when appropriate.
WORKER’S COMPENSATION:
We require approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full. If you have health insurance, the claim may be filed with you health insurance. Be aware, however, that your health insurance may refuse to pay if there is third party liability, e.g., another responsible party in the case of an accident with litigation.
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.
I HAVE READ AND UNDERSTAND THE ABOVE, AND I AGREE TO THE TERMS OF THIS AGREEMENT.
Patient’s printed name_______________________________________________________________
Person responsible for payment (if not the patient)_________________________________________
Signature__________________________________________________________________________
Date___________________________
Co-signature (if required)______________________________________________________________
Date___________________________
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