Uninsured patients. For any patient without current active insurance, non-participating insurance plan or a lapse in coverage, we are happy to see your child for a visit according to the fee schedule listed below. We are happy to provide you with a detailed billing summary for submission to your insurance company if non-participation or lapse in coverage has deemed your child/ren a self-pay patient on the date of service. Effective May 8, 2012, all self-pay patients will be placed on a discounted sliding fee schedule. For the patient to receive the discounted sliding fee schedule rates, payment for services must be paid in full at time of service. If you have a question about the discounted sliding fee schedule, you may contact the office. NEWBORNS Congratulations on the birth of your newborn baby! Below is important information regarding insurance coverage. It is extremely important that you notify the insurance company immediately following the birth of your child to initiate the process of enrollment. Your visits during the first 30 days will be billed as a Self-Pay/Temporarily Held Claim while we are waiting for your insurance company to add the new baby to the existing policy. If our office is not able to verify insurance coverage with the insurance company after your child’s 31st day of life, then we must assume that your child is uninsured and the visit will become patient responsibility in addition to all previous visits on our Sliding Fee Schedule. Once you have obtained the new insurance information from the insurance carrier, please notify our billing department so that we may retroactively submit your claims for processing. Common Issues You Should be Aware of:
Uninsured patients if you are uninsured, a free estimate of expected charges based on anticipated services will be provided to you. We require a deposit of $200 prior to receiving services. This amount can be paid in cash, debit/credit card. The final charge will be determined by the provider at the completion of your visit. A refund will be immediately issued should the charges be less than the deposit. If the charges exceed $200, payment is required at that time. Referral: You are responsible for obtaining any necessary referral if required by your insurance company. If referral is not obtained and is necessary, you are responsible for full payment. Please initial each statement: I authorize release of information to all insurance companies I authorize and direct payments of podiatric services directly to Stride Foot & Ankle Center, LLC I understand that a $40 No Show fee will be charged if I don’t cancel or reschedule my appointment within 24 hours. I understand that there is a $40 charge for returned checks (NSF) and that in such event, I will no longer be able to pay with check for future appointments. I understand that balances 30 days overdue will incur a 1.5% late fee per month and are subject to collection report. I have read, understood and accept the terms stated above. I have been given a copy of this financial acknowledgement. Printed patient name Patient Signature/Responsible Party / /
Uninsured patients. If you do not have insurance, payment is required in full at the time of check in.
Uninsured patients. At all times during the Term, the Parties shall work collaboratively and exercise their commercially reasonable efforts to secure funding from the State for the cost of the services provided to uninsured patients who are provided services by the Facilities.
Uninsured patients. Massachusetts offers affordable insurance plans for those residents who have no health insurance. If you need assistance with information, please contact our office. If you have no insurance the following payments are required to be paid prior to receiving services. • $85 for a sick appointment of an established patient. • $100 for a sick appointment of a new patient • $150 for a well visit You will be billed at a “self-pay” rate for any additional costs incurred for the visit (see attached fee schedule). Please let us know if you have questions. A copy of this agreement will be provided upon request. I have read and understand this financial policy and agree to abide by its guidelines. Date
Uninsured patients. We offer a $75 flat fee per routine visit, payable at the time of service, for patients who do not have insurance. The flat fee for physicals is $120. Charges for any labs, treatments, X-rays or other tests are your responsibility. A sliding fee scale may be available for low income patients.
Uninsured patients. A 10% discount will apply to patients not having insurance when paying 50% of balance on the day of service. Total $ Discount: $ Patient Due:$ 2nd Payment Due: Plan B: 50% of Estimated portion Due At Time of Service (2 Month Plan) Pay 50% of estimated portion on day of service, then remaining balance will be paid over 2 months in 2 equal payments. 50% Due: Date: Remaining Balance$: Payment #1 Due: Payment #2 Due: Payment Amount$ Plan C: 50% of Estimated Portion Due At Time of Service (3 month plan) 50% of estimated portion due on day of service, then remaining balance will be paid off in 3 month increments. 50% due: Date: Remaining Balance $: Payment #1 Due: Payment #2 Due Payment #3 Due: Payment Amount $
Uninsured patients. We offer a cash pay discount to our patients who do not have insurance. Please be advised that the discount is only good when the charges are paid at the time of service. If the charges are not paid at the time of service, the discount will be removed and payment of the full charge will be expected before the next visit. If a balance remains, you will receive a monthly statement that is due upon receipt. Any account balance over 90 days will be subject to review for collection action. (initial)
Uninsured patients. Are responsible to pay cash rate at the time of service to receive reduced rate.
