Thank you for choosing the Arthroscopy and Sports Medicine Clinic for your sports and orthopaedic care. To keep you informed of our current office and financial policies we ask that you read and sign our office and financial policies prior to any treatment. Please keep this document for future reference.
Credit Card Policy: The Arthroscopy and Sports Medicine Clinic requires a valid credit card or bank debit account information prior to services being rendered. Your credit card or account will not be charged until 60 days after the services provided have been processed by your health insurance carrier and the balance deemed your responsibility. You will be notified by letter and/or phone of any outstanding balances prior to charging your card or account, at which time you may choose your payment option.
Cancelled Appointments: As a courtesy to other patients waiting for appointments, please give us at least two weeks notice if you need to reschedule. There will be a $50.00 same day cancellation fee required for cancellations made less than 24 hours in advance.
Cancelled or Rescheduled Surgical Procedures: As a courtesy to other patients waiting for surgery, please give us at least two weeks notice. The need to cancel or reschedule your surgical procedure within one week of surgery will result in forfeit of your deposit.
Surgical Assistant: Should you require surgery, an assistant familiar with Dr. Faryniarz’s instruments and techniques will be provided. The assistant may be another physician or a physician assistant. The usual fee for the assistant surgeon is approximately 25% of the surgeon’s fee. Some insurance carriers do not provide benefits for assistant surgeons. Where insurance carriers deny coverage, we will reduce the fee to $250.00; this will be collected as your deposit at the time of booking surgery to hold your surgical date. It is 100% refundable if you cancel at least one week prior to your scheduled date. Our staff will still bill your insurance carrier, if paid, will issue a refund or apply towards your surgical balance.
No Insurance: Payment will be due at the time of service. If you are unable to pay your balance in full, you will need to make prior arrangements with our Financial Counselor. We do offer payment plan options.
Insurance: Please bring your insurance card with you at the time of your appointment. For insurance plans that we contract with, your carrier requires that all co-pays be paid prior to any services being rendered. The co-pay requirement cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier. If you do not have your co-pay at the time of your visit, you must provide us a written waiver from your insurance carrier specifically authorizing the Arthroscopy and Sports Medicine Clinic to waive this obligation.
You are responsible for any co-insurance, deductibles or non-covered services as required by your insurance. You will receive a statement from our office indicating what your insurance has paid. Any remaining balance is due upon receipt of the statement.
DME: Durable medical equipment (DME), such as braces and ice machines, are handled through an outside vendor. Our office will help with authorization of recommended DME; however, it is your responsibility to check with your insurance benefits for coverage of the equipment.
Auto Accident Injury: We do not accept auto accident liens. Payment for any services rendered will be your responsibility.
Return Checks: A $30.00 charge will be added to your account for any check returned by your bank.
Disability or Insurance Forms: There will be a charge of $15.00- $35.00 for the completion of medical forms (charge is based upon number of pages and complexity of information requested). Payment is due at the time that you pick-up the forms. Please allow 7-10 days for the completion of these forms. If you would like the forms mailed to you or your insurance company, payment will be due prior to mailing.
Medical Records: We will provide you a copy of your medical record upon request. You will need to sign a letter of release at the time of pick-up. Please allow one week for us to copy your records. Depending on the extent of your record, there may be a small charge for copying and/or mailing your records.
I acknowledge full financial responsibility for services rendered by the Arthroscopy and Sports Medicine Clinic. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including coinsurance, deductibles and co-pays. I understand payment of co-pays is expected at time of service, as well as any prior balance I may owe. I also consent that the payment of authorized Medicare insurance benefits be made on my behalf directly to Arthroscopy and Sports Medicine Clinic for any medical or surgical services furnished. I agree to all reasonable attorney fees and collection costs in the event of default of payment of my charges, as outlined in the office and financial policies guidelines.
Acknowledgment – Notice of Privacy Practices
I hereby acknowledge receipt of Arthroscopy and Sports Medicine Clinic’s Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential health information.
I understand that the Arthroscopy and Sports Medicine Clinic has reserved the right to change its privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided or made available to me.
Signed:__________________________________ Date: ______________________
If you are not a patient, please specify your relationship to the patient______________