Financial Policy Form

This is an agreement  between Lone Star Orthopedics, P.A. , as a 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 are

credited. The words "we", "us", and "our" refer to Lone Star Orthopedics, P.A. By signing this agreement

you also agree to our Financial policy. 

Insurance

Insurance is a contractthis contract, in most cases. We will bill your primary insurance company as a courtesy to you. 

Although we 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 or pre-authorization for care, you

are responsible for obtaining it. Failure to obtain the referral or pre-authorization may result in 

a lower payment from your insurance company. In the case of surgery, we will obtain pre-authorization

if you provide us with your correct and current insurance information. 

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 for insufficient funds.

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

and all court costs. In case of suit, you agree the venue shall be Hays County, Texas. 

Waiver 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 in 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 medical records sent to another doctor or organization. If the request if for 

medical care, we will fax our records to another doctor free of charge following your authorization.

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 wil be responsible for your payment in full. 

Co-signature

If this or another Financial Policy form is signed by another person, that co-signature remains

in effect until cancelled in writing. If writtent cancellation is received, it becomes effective with 

any subsequent changes. 

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. 

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

Monthly statment

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 privilige 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. We are contractually required

to do this by your insurance plan (including Medicare).

3. You can choose to pay all of your treatment by cash, check, or credit card. We will file 

your claim for you and request your insurance carrier to send the 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.

Less Than 24-hours Notice Fee

1. Lone Star Orthopedics tries to see patients rapidly for injuries and urgent needs, but we must have open appointment slots to do this. 

When a person cancels or reschedules with less than 24-hours notice, or does not come to the appointment without notice ("no-show"), 

this leaves an empty appointment slot that could have been filled by a patient who wanted to be seen sooner.

2. In an attempt to decrease the number of cancellations or rescheduled appointments with less than 24 hours notice

or "no shows", Lone Star Orthopedics will charge you a $25 fee for less than 24-hours notice/no-show that must be paid

at your next appointment. 

3. NOTE WELL that this fee will not be paid by your insurance company. Health insurance covers the cost of 

health care, not missed appointments. THIS INCLUDES WORKERS COMPENSATION PATIENTS.

By signing this document, you are acknowledging that you have read the above policy and agree to this financial policy.

______________________________________                              __________________________________________________

Patient's name                                                                         Signature of person responsible for payment

Di

an

________________________________________                                 ________/________/__________

Signature                                                                                                               DATE

_______________________________________                                   ________/_______/__________

Co-signature (if required)                                                                           DATE