Also I need our payment policy on https://daytonfeet.com/patient-welcome-form/ to be updated to the text below.
Thank you for choosing Community Foot Specialists as your foot care provider. We are committed to providing you with the highest quality of health care and strive to keep healthcare affordable in our office. As such, we provide this document to ensure your understanding of the payment policies. Please read the following office payment policy carefully and feel free to ask us any questions that you may have. Once you review this policy, kindly sign in the space provided on your welcome sheet. This will serve as your acknowledgement and acceptance of this policy. A copy of this policy can be provided to you upon request.
- Registration. It is important that we be able to contact you with medical information as quickly as possible. Each time you arrive at the office for a scheduled appointment, we will verify your address and contact numbers and make a copy of your insurance card. Please notify us immediately if any contact information changes so that we can be in touch with you. Bring your insurance card(s) with you so that we can keep your account updated. Once a year, we will ask you to sign a new registration form that gives us permission to not only treat you, but file insurance claims and provide your insurance company with information that they have requested regarding your health care. All these forms must be signed by an adult: no minors are to sign consents, even if they are the patient.
- Insurance. All insurance cards are expected at each visit. We participate in most insurance plans, including Medicare and Medicaid. If you are not insured by a plan we participate with, payment in full is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
- Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. You are responsible for your bills until your insurance makes payment and all non-covered portions of your bill. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. For your convenience we accept cash, check, money order, Visa and MasterCard.
- Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit.
- Proof of insurance. All patients must complete our patient information form before seeing the doctor. On your first visit, we must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. On subsequent visits, a current valid insurance card must be provided as proof of continued insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
- Referral. Referrals are often not required for podiatric care, but some insurances still require a referral. If required, obtaining the proper referral from your primary care physician is your responsibility. Any balance due do to the lack of getting the proper referral will be the patient’s responsibility and payment in full will be expected.
- Claims submission. As a service to you, we will prepare and submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company.
- Coverage changes. If your insurance changes, please notify the front desk at your next appointment so that the appropriate changes can be made to help you receive your maximum benefits. Failure to provide us with new insurance cards may cause problems since most insurance companies allow up to 2 months to submit a claim with correct information. After 2 months insurance may automatically deny the claim for exceeding the time limit for filing a claim.
- Nonpayment. Invoices/statements are sent out every 24 days. Your prompt payment will assist us in keeping the cost of healthcare down. If three statements have been sent out, and no payment has been received, you will receive a letter letting you know that your account is now delinquent and heading for collections. Once your account is put in collections, an additional collection fee will be applied up to 40%. Please be aware that if your account goes in to collections, we will be unable to see you until full payment is received. Partial payments will not be accepted unless otherwise approved by our billing department. You are financially responsible for all charges, whether or not paid by insurance.
- Bounced checks. All checks that are retuned for insufficient funds will be assessed a $25.00 reprocessing fee.
- Appointment Scheduling. For your convenience, we offer both pre-booked and same day appointments. Same day appointments make care available to you when you need it and are best suited to patients with acute needs. You must arrive before your arrival time to allow adequate time for registration, handling payments and information that may be needed before your visit. If you arrive late, we may have to reschedule your appointment on another day.
**Each patient is important to us and we are dedicated to providing necessary care. Unpredictable situations may occur with patients who require extra attention during the course of the day. We appreciate your understanding when there are delays. The same courtesy will be extended to you when you have additional needs.
- Missed Appointments/No Shows.If a patient no shows/misses an appointment, the patient will be subject to pay a fee and we will send out a no show letter. The patient will receive a no show/missed appointment letter for each appointment missed. Once the patient has missed three missed appointments in one calendar year, the third letter will state that the patient may be dismissed from the practice. If any questions please ask for a copy of our no show / missed appointment policy. Please help us to serve you better by keeping your scheduled appointments.
- Messages. Our physicians and staff are in constant communication. If you call the office with a question, we will relay your concerns to the physician. A staff member will return your call. When leaving a message, please specify your name, date of birth, the physician you see, and the reason for your call. Although we attempt to return your call the same day, it occasionally may be the next day.
- After Hours Care. If you have a life-threatening emergency, dial 911. If you need to contact the office or a doctor after hours, you may call and leave a message. All messages are followed up on the next office day. The office numbers are:
937-322-7607 (Springfield area) or 937-426-9500 (Dayton area).
- Medical Records. You have a legal right to access your medical records. To facilitate this, we are able to provide for you copies of your medical records for a charge. There is a service charge of $20.00 plus an additional charge per page. All payment is due in full before records will be released. You will need to allow us 7-14 working days to prepare the medical records. Please contact our medical record department for further details.
- Forms and Documents. Due to administrative cost, it is our policy to charge $20.00 per company for completion of all forms or documents, such as disability applications, FMLA papers, etc. Please allow 7-14 business days for forms to be completed. All payment is due in full before forms will be released or faxed.
- Test Results.All test results we be gone over in the office with the doctor. No results will be given over the phone. Typically, it takes up to one week to get test results back. Please be aware that some test processing takes longer than others.
- Prescription Refills. Our physicians carefully prescribe so that you will have enough medication. If you run out please check with your pharmacy to see whether there are refills available. If you are running out and there are no refills available, it is most likely time to come in for a checkup.
- Patients under the age of 18. It is our policy that, anyone under the age of 18 be accompanied by an adult. If the parent or legal guardian is unable to accompany the patient, then we are required by Ohio law, to have written permission for treatment from a parent or legal guardian. If we do not have this at time of visit we will be unable to see the patient. A permission slip for ongoing care is available in the office or you may send a signed note each time the patient is seen.
- Fees. Our fees are representative of the usual and customary charges for our area.
***Please acknowledge acceptance of the Payment Policy by signing your name on page 4 of your Welcome Sheet***