Reconstructive Hand to Shoulder of Indiana
OFFICE AND FINANCIAL POLICIES
We require you read and sign this
document prior to any treatment
Your clear understanding of our financial policy is important to our professional relationship. Please feel free to ask, should you have
any questions about our fees, financial policy or your responsibility.
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Canceled appointments: If you are unable to keep your scheduled appointment, please call our office within 24 hours to
reschedule. This allows us to offer that time slot to another patient. We reserve the right to charge a fee for appointment
cancellations of less than 24 hour's notice.
Responsible Party: Payment in full is due at time of service if you do not have health insurance or cannot provide our office
with adequate billing information. You will be responsible for your charges regardless of any divorce decree or court order
regarding payment of medical bills. We do not accept third party insurance. Therefore, if your medical condition is a direct
result of a motor vehicle accident, and you are not filing through your private health insurance, you will be responsible for
payment in full at the time of service. Your account will be charged $30.00 for each time a check is returned for nonsufficient funds. If these checks are not honored by your bank, you will be responsible for the payment of the check and
additional charges within ten days.
Insurance: Insurance is a contract between you and your insurance company. In some cases, we are NOT a party to this
contract. We will not become involved in disputes between you and your insurance company regarding deductibles, copayments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual
information as necessary. You are responsible for timely payment of your account. With insurance plans where we have
agreed to participate in the network as a provider, your carrier requires all co-payments be paid at the time of service.
Federal and Managed Care contract law requires this office to collect co-payments for each encounter. The co-payment
cannot be waived by our practice. If you do not have your co-payment at the time of service, you must provide us with a
written waiver from your insurance carrier specifically authorizing RHSI to waive this requirement. Otherwise, there will be
a $10.00 service charge for statements generated for your co-payment, should you not pay at the time of service. If your
insurance information changes during treatment or at any time you receive services from us, it is your responsibility to
provide us with the current and accurate information. RHSI cannot be responsible for any penalties or denial of payment as a
result of incorrect information. HMO or POS: If your insurance requires a referral from your primary care physician (PCP),
it is your responsibility to obtain that referral from your PCP prior to services rendered. If you arrive at the office without a
referral and are unable to obtain one by telephone at the time, you will be responsible for the visit in full or will be asked to
reschedule the appointment. Should you require ancillary services (diagnostic testing) please be familiar with your insurance
policy so that we can assist in directing you to an appropriate provider to minimize your risk of incurring out-of-network
benefits. It is your responsibility to know your insurance requirements. Please advise our staff if your insurance company has
special requirements such as pre-certification or second opinions prior to surgery. We do all we can to help, but the ultimate
responsibility for fulfilling special requirements rests with the patient. Being familiar with your insurance benefits will help
avoid payment misunderstandings.
Collection Policies: If you are unable to pay your balance in full, you will need to make prior arrangements with our Billing
Representative. Should you need to make payment arrangements; a signed payment agreement must be on file to accept
payments toward your balance. We will accept four (4) equal monthly payments to settle the account. Should your account
become 90 days delinquent it may be subject to a 1.5% interest charge accrued monthly. Delinquent account balances over
150 days may be referred to an agency for collection. Patient care with our office may be cancelled once your account goes
to collections.
Disability Forms, FMLA, AFLAC, etc: There will be a charge of $30.00 for completion of short/long term disability
forms, Family Medical Leave Act forms, or other insurance forms, payable prior to completion. These will be completed
within 3-5 business days after receipt of payment. Your portion must be completed and signed prior to completion. If you
are scheduled for surgery, please contact your employer’s Human Resource Department for instructions on forms should you
require a leave of absence. Do not wait until the day of surgery.
SEE REVERSE SIDE
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Medical Records Request: We will provide copies of your medical records upon request. You will need to sign a letter of
release. Please allow 5 – 7 business days to process your request. There may be a fee for copying medical records and
postage due to the size of the patient’s chart.
Worker’s Compensation: If your visit with our physician is due to a work-related incident, please be sure to contact your
employer and inform them of your appointment. Failure to properly report this to your employer may result in denial of your
claims. Denied claims may become your financial responsibility. Prior to your visit we must have complete billing
information to include:
1. The name of the compensation carrier, address for mailing claims
2. Your claim number
3. The telephone and facsimile number to the adjuster and/or case manager
Should you require Surgery: Surgery consists of schedule coordinating with the surgeon, anesthesiologist, nursing staff
and the facility. If you are unable to keep your surgery date, please be respectful of all those involved by calling our office
within 48 hours.
Surgery Co-Insurance/Deductible: In order to assist you with your surgical needs, our office will contact your insurance
company to determine eligibility and benefits, as well as pre-certification prior to surgery. If there is any unmet deductible at
the time of surgery, it is the policy of RHSI to collect that deductible prior to your surgery date. Arrangements can be made
with our billing representative.
Post-Operative Care: There is a 90-day postoperative global period. During this time, you will not be charged for postoperative related visits with your surgeon. However, there will be additional fees for any x-rays the surgeon should request
during this time. In addition, visits with our occupational therapists, as well as durable medical equipment (splints,
theraputty, therabands, gloves, exercise equipment, etc) are chargeable during the 90 days after surgery. You will receive a
separate statement for your surgery from the facility and the anesthesiologist.
PLEASE NOTE: If you are released to return to work with restrictions and/or prescribed medication, it is your responsibility
to comply with all applicable rules of law required in the operation of a motor vehicle.
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Medicare Certification: I certify that the information given by me in applying for payment under Title XVIII of the Social
Security Act is correct. I authorize my physician who treats me, to release information from my medical record to the Social
Security Administration and/or the Medicare Program or it’s intermediaries or carriers, or to the Professional Standards
Review Organizations for processing of claims for medical benefits. I request that payment of authorization benefits be made
directly to my physician treating me, on my behalf.
Financial Agreement: I understand all accounts are the full responsibility of the patient and/or the patient’s responsible
party/guarantor. In the case of default payment, I agree to pay any legal interest on the balance due along with any collection
costs and reasonable attorney fees incurred to effect collection of my account or future outstanding accounts.
Consent to Treat: I request and give consent to my physician to provide and perform such medical/surgical care, tests,
procedures, drugs and other services and supplies as are considered necessary or beneficial by my physician for my health
and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to
me or relied upon by me.
I, the undersigned, have read, understand, and agree to abide by the above information.
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Patient/Guardian signature
052814
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