ASSOCIATED FOOT AND ANKLE CARE NOTIFICATION OF OFFICE POLICIES AND PROCEDURES

1. APPOINTMENTS: To allow for greater access of care, our team of physicians is available by appointment during posted hours.
2. Emergency/After: During a medical emergency, patients should call 911 or proceed to nearest emergency room.
3. Refills and Medication: Refills are completed via a pharmacy request.  Contact your plan regarding your drug coverage.
4. Messages: Phone messages received before 3 pm are usually returned daily.  Emails are returned less frequently.
5. Benefits: We will reiterate the benefits that were disclosed to us by your insurance plan.  We will then collect based on the benefit level all applicable copays, deductibles, coinsurance and balances that apply at the time of service or at the pre-operative appointment.  To improve accuracy, we update records annually.
6. Payment: We accept VISA, MasterCard, American Express, Discover, check, cash.  Our office does not accept temporary checks.
7. Referrals/Labs: We may refer patients to other providers, facilities and labs. We are not responsible for these entities. It is patient responsibility to confirm coverage with his/her insurance for any labs sent out. Patients should contact these facilities directly regarding any billing questions.
8. Missed Appointments: A $25 charge will apply to appointments broken or canceled without a 24 hours advanced notice.
9. Appointment Hold: Repetitive broken appointments, non-compliance, hostile behavior, and/or financially deficient accounts will result in appointment hold and/or the termination of Associated Foot and Ankle Care Patient relationship.  30 days’ advance notice will be given should the situation result in transfer of the patient care.
10. Delinquent Accounts: Past due accounts are subject to collection proceeding and are reported.  All collection fees, attorney fees and court fees shall become the guarantor’s responsibility in addition to the balance due the office.
11. Returned Checks: A $25 fee will be assessed on all returned checks.  Any NSF or Closed Account will result in future services on a pre-pay cash or credit basis.  The District Attorney’s office will prosecute unresolved checks.
12. Refund: Only unworn and non-custom items are returnable within 14 days of receipt, if no visible signs of wear, tear, or order.  Custom items are tailored to meet individuals’ needs; custom items are non-returnable, non-refundable.
13. Medical Records: The cost of copying medical records is $1 for the first 25 pages and $.25 cents for each page thereafter. We require a written request, please allow 5-7 business days for replicating. The cost of copying medical records will be charged to the patient and collected prior to releasing records. There is no charge for records faxed to another physician.
14. Secure Portal: Patient messaging, instructions, clinical summaries and patient records are provided online.
15. Pets: Only service Animals are permitted.
16. Paperwork: All FML paperwork, Disability Claim documents and any other documents that require doctor’s signature will have a fee of $35, the fee will be charged to patient. Please allow 5-7 business days for completion.

The undersigned certifies that he/she has read and understands the foregoing 1-16 statements, and is either the patient, or is duly authorized by the patient as the patients’ general agent to execute the above and accept its terms.

You will be given the ability to sign once you’re in the office.