Thank you for choosing Active Foot & Ankle as your health care provider. We are committed to the successful treatment of your condition. Please understand that payment of your bill is considered part of your treatment. Should you have any questions regarding any aspect of your financial status with our office, please feel free to contact our billing Specialists Becky or Karin at (512)869-1100 or (440)279-4288.

Your clear understanding of our Financial Policy is important to our professional relationship.

WE ARE HAPPY TO BILL YOUR INSURANCE DIRECTLY; HOWEVER, WE MUST HAVE A COPY OF THE INSURANCE CARD

IF YOU DO NOT HAVE YOUR INSURANCE CARD WITH YOU, FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECK, VISA/MASTERCARD, AMERICAN EXPRESS AND DISCOVER.

ALL PATIENTS MUST COMPLETE OUR “PATIENT REGISTRATION FORM” AND OTHER RELATED FORMS.

PLEASE, NOTIFY US IMMEDIATELY OF ANY CHANGES IN YOUR INSURANCE OR COVERAGE.

5 BUSINESS DAYS NOTICE IS REQUIRED FOR COPIES OF MEDICAL RECORDS OR X-RAYS AND THERE MAY BE A NOMINAL FEE.

Self Pay: We expect payment at the time of service unless prior arrangements have been made.

Medicare: We accept Medicare assignment. As a Medicare patient, you are responsible only for the deductible if you have supplemental insurance. A few services and supplies are not covered by Medicare we will advise you of any non covered charge prior to the service being provided.

HMO/PPO: ALL CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE if not a $10.00 service charge will be added. IF YOU DO NOT KNOW YOUR CO-PAY, YOU MAY USE OUR PHONE TO FIND OUT. We are members of most, but not all plans. You are responsible for verifying that we are providers for your plan. If you are an HMO member, you will not be billed as long as we have the necessary referrals.

Please note: You must have your referral at the time of the visit or your plan requires that we ask you to reschedule.

PPO patients will only be responsible for their deductible, co-payments and co-insurance, as long as they have verified with their insurance that our physician is in their plan.

Workers’ Compensation: If you are here because of a work related injury, we will require information regarding both health insurance and your employer’s Workers’ Compensation insurance. Before seeing a doctor, we will require a letter or statement from the Workers’ Compensation carrier authorizing your treatment. The letter should include the claim number, address, adjuster’s name and phone number. (Your employer’s human resources office should be able to assist you with obtaining this information.) If payment is not received from these third parties within 90 days, we have the right to bill you directly.

Hospital and Surgery Center Charges: In the event that you undergo surgery in a hospital or ambulatory surgery center, a separate charge will be made by that facility.

Self-pay patients – Payment in full is due at the time of service.

Patients with Insurance – We will file your insurance claim for you. However, in order

to work with your insurance company, we must have complete and current information as well as a copy of your insurance card and your signature on file.

Denied Claims – You will be responsible for any charges that are denied by your

insurance company which result from your failure to provide our office with complete and

current information in a timely manner. It is your responsibility to inform us of any changes in insurance benefits.

Referrals– If your insurance requires that you obtain a referral from your Primary Care Physician, it is your responsibility to ensure that our office receives the referral prior to your visit.  If a referral is not in place, you will be responsible to pay in full at the time of service. If the doctor schedules a test for you, please check with your insurance to see if a prior-authorization is required (as this must be completed before testing is performed).  Although we do our best to check for you, it is ultimately the responsibility of the patient.

Durable Medical Equipment– Our office will assist in determining coverage for Durable Medical Equipment (braces, splints, boots, walkers, and/or orthotics as needed). Active Foot and Ankle makes every effort to verify active coverage, but we are not always able to check benefits on all patients, due to regulations of various insurance companies and contract agencies. All processes and procedures must be listed and billed according to HIPPA (Health Insurance Portability and Accountability Act) guidelines by Active Foot and Ankle for accuracy and liability purposes. This means any and all procedures, treatments and care will be billed to you and your insurance. This does not guarantee payment by your insurance company. Any item not covered by insurance is deemed “patient responsibility.”

Insurance benefits – It is your responsibility to know your insurance benefits. Please

contact your insurance company with any questions that you may have regarding

coverage of podiatric services.

Copayments, Co-Insurances and Deductibles – All patient balances are due at the time of service. Patients with private insurance plans (non-Medicare/Medicaid) that include deductibles will need to pay a $100.00 deposit at the time of service. If copays are required by your plan, payment at time of service will also be due. Active Foot and Ankle reserves the right to refuse treatment if required payments are not made at the time of service. For your convenience, all major credit cards are accepted.

Non-Covered Charges – Please understand there may be some charges for our services

which your insurance company considers non-covered and may be excluded from your

policy. Accordingly, you will be responsible for these charges.

Medicare – We are a participating Medicare provider. We will bill Medicare, as well as any

secondary insurance that you may have. As per any insurance carrier, this does not mean that all services will be covered. Additionally, if you do not have a secondary insurance, you will be responsible for any copayments (20% of the Medicare allowed amount), as well as any unmet annual deductibles. Please realize that Medicare may allow a service, but your secondary may not, so you will be responsible for that portion.

Returned checks – Any returned check is subject up to a $45.00 bank fee.

Past due accounts – We will send a statement to the mailing address you provide notifying you of any outstanding balances. If you do not respond to the first statement within 30 days of receipt and additional statements are mailed, a $10 re-billing fee will be added each month. If you are not able to pay your balance in full, you must contact out billing office to discuss a possible payment plan. If you then fail to make payments, your account may be referred to a professional collection agency and/or attorney and will be subject to a 35% fee.

I understand that I am financially responsible for all charges not covered by insurance and I guarantee the balance to be paid by my credit card, check or cash. Past due balances may be subject to additional fees.

UCR (Usual and Customary Rates)
We are committed to provide the best treatment possible for our patients and we charge what is usual and customary for our area. If we do not have a contract with your insurance company, you are responsible for payment in full regardless of any insurance company’s arbitrary determinations of UCR rates.

I understand that if the office agrees to bill insurance as a courtesy, I must submit information as needed to ensure payment for services rendered to me. I understand that I am ultimately responsible for payment for all services.

If payment is not received from the insurance carrier or other responsible party in 90 days, I will be billed directly.