Appointments: ______ (initial)
Our office hours are 8 am-12pm, and 1pm-5pm Monday through Friday. Please note that Fridays the Doctor does leave at 12pm for the rest of the day but staff does remain here until 5pm for any questions you may have.
Financial Policy: ______ (initial)
An estimated payment is due at the time of service by cash, credit card (We do NOT accept American Express)
Patients are responsible for copays, deductibles, and co-insurance if applicable at the time of service.
Any balance on an account that is greater than 30 days old is considered past due. A statement will be mailed on a monthly basis and will reflect the current balance for all services rendered prior to the date on the statement, Payment is due upon receipt of statement.
Insurance: _______ (initial)
Your insurance policy is a contract between you and your insurance company. While our billing professionals will do all they can to help our patients in communicating and negotiating with their insurance plan or other persons, we must inform patients that have any questions regarding coverage, benefits or payment for services provided, is their responsibility to resolve.
In the event of denials, errors, or non-covered services. (The patient is responsible for all services rendered. If payment from your insurance carrier is not received within forty-five (45) days, we will seek full payment from you.Balance of services that are delayed or denied by your insurance company due to Coordination of Benefits information will become your responsibility after thirty (30) days. Dallas Ortho and its employees do not guarantee that payment will be authorized for medical services: therefore this office is not responsible for any adverse payment decisions or misuse of information.
Notification of any change in your insurance status (i.e. new company, deductible, co-pay amounts) must be provided to the office forty-eight (48) hours in advance of next visit, or payment in full will be required.
Red Flag Policy: _________ (initial)
Dallas Ortho store our patients' private medical,financial, and personally identifying data. We must therefore be vigilant in protecting the patient information to which we have access including medical, financial, and any other personal information contained in medical, appointment or billing records."
You must present a valid state issued photo identification card and if you would like us to bill your insurance carrier, you must present a valid insurance card and identification card prior to being seen at each appointment, or payment in full will be required.
Miscellaneous Charges: _________ (initial)
For medical records you will be charged $25.00 and may take up to 3-5 business days to obtain.
If you do not cancel your appointment 24 hours in advance our policy is to charge the rate of $35.00 and is payable prior future visits. These will not be billed to your insurance company. Please help us to serve you better by keeping your scheduled appointments or canceling in advance.
Refill Requests: __________ (initial)
All requests for prescription refills must be made through your pharmacy. Your pharmacy will send us a refill request on your behalf, this will be the only way we can refill your medication if you are calling the office for them. If it is a narcotic you will need to schedule an appointment to be seen.
Emergency Situations |After Office Hours: ________ (initial)
Any phone messages left after 4:00pm Monday through Friday will be returned the next business day.
In the event that you call our office and the doctor is out, your call will be returned the next business day.
If you feel that your call needs urgent attention you should go to the nearest emergency room or urgent care.
I have read and understand the Office/Practice, Privacy Policies and I agree to accept responsibility as described. If you have any questions, please feel free to ask our staff for assistance. Thank you for choosing us for your care.