Form 2

Financial Policy for Facaros Foot and Ankle

Thank you for choosing our office as part of your health care team, we will do our utmost to provide you with the finest care possible and are grateful for your decision to choose our practice. In our effort to provide personalized care in the most efficient and economical manner possible, we are providing all our patients this copy of our Financial Policy. We ask that you take a few moments to read it and sign below.

Insurance Coverage

 Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. If you have private insurance, our billing service will submit your claim for payment. If you do not have insurance or we do not participate with your insurance, you will be expected to pay for your visit and/or procedure before leaving.  New insurance companies are continually forming while existing insurance companies are rapidly changing. It is your responsibility to know the specifics of your policy (referral requirements, in & out of network physicians and facilities, etc.). Most private insurance policy plans (non-Medicare/Medicaid) now have deductibles, copayments, coinsurances, maximums and limitations (out of pocket expenses). If your annual out of pocket expenses have not been met, you will be required to pay a $125 deposit at the time of your visit. This will be applied to your account and a statement will be sent reflecting any additional monies owed following response from your insurance carrier. If it has been stated by your carrier that a deductible deposit cannot be collected at the time of service, a valid credit card will be required and stored securely. Upon claim response, your credit card will be charged, and a detailed statement will be provided along with a paid receipt.  We rely on you to inform us of all insurances in effect and to notify the office immediately of any changes with your insurance. It is required that you bring in your insurance card and proof of identification at the time of your visit and any visit thereafter. If you do not inform us of changes, you will be responsible for the services rendered. When multiple policies exist, it is the patient’s responsibility to inform us which policy is the primary plan.   If we are not provided ALL insurance information at the time of service, you will be responsible for paying directly and then submitting for reimbursement from your insurance company.

  • For patients in the Medicare program, please realize that you are responsible for paying the deductible and 20% of the accepted fee that Medicare allows.
  • For patients who have HMO/managed health care plans, copayments are expected to be paid the day services are rendered.
  • If a referral form is required, it is expected that you will bring it with you the day of your visit. If it’s not present, we will kindly ask you to reschedule for another time.
  • You will be held responsible for any remaining balance not covered by your insurance. Our billing service sends out bills monthly. Please do not ignore these bills. If the billing cycle completes and payment has not been received, we will then employ the use of a collection agency.
  • If you receive a bill that you question, please call us. We try our best to make office visits/services affordable. We understand that economic matters are at the forefront in daily life, frustrating for patients and physicians alike. If you’re haǀing financial difficulty, please discuss it ǁith us and ǁe ǁill work with you to accommodate as much as possible.
  • We realize there are many options for Foot and Ankle specialists. We are thankful to you for making us your choice and we look forward to working together.

Appointment Charges

  • All charges are the responsibility of the patient. We will bill your insurance company, but any services deeŵed as ͞not covered͟ are the patieŶt’s responsibility. If you do not have insurance, you are responsible for all services rendered. Co-pays will be collected at the time of the appointment (as required by insurance companies). For new patients, we will make every attempt to contact your insurance company to determine your office visit copayment, if any. Existing patients should notify us of any changes related to copayment amount right away.
  • Costs can vary, depending on the type of insurance coverage you have and the treatment for your particular condition(s.) Cost/payment by your insurance company cannot be guaranteed by our staff. If you have any concerns, we advise you to contact your insurance company.
  • If you miss an appointment or cancel an appointment less than 24 hours prior to the appointment time, you may be assessed a $50.00 fee, as we have reserved that time slot just for you. Missed appointment fees are the responsibility of the patient.
  • A $25.00 fee will be assessed on all returned checks.
  • Balances/Collection Fees: If balances are not received within 30 days of the postmarked date on a mailed statement, a finance surcharge/rebilling fee will be added to each additional statement. This fee is determined by an outside billing agency and is based on a percentage of your outstanding balance. Past due accounts more than 90 days will be turned over to a collection agency and a $35 administrative fee will be added to the account balance.
  • For forms requiring completion by Facaros Foot & Ankle, such as, but not limited to: Disability/School/Athletic/FMLA/Assistance programs, they carry a $25 charge and we ask to allow for 7 days until receiving back. We apologize for the fee, unfortunately this is due to the ongoing increased time restraints placed on providers by insurance companies.

I hereby consent and authorize Facaros Foot and Ankle (FFA) to release to the Social Security Administration and Centers for Medicare and Medicaid services, its intermediaries or carriers, and to any other insurance or managed care company covering me or my dependents or insurance beneficiaries, any information, including protective health information, needed for processing of claims for payment for services rendered. I request that payment of Medicare, insurance or managed care benefits for services rendered to me (or my dependents/beneficiaries) be made directly to FFA. I further understand and agree that if my insurance plan sends payment to me rather than FFA, I will endorse/forward the check to FFA to apply towards my account.

Financial Policy for Facaros Foot and Ankle

427 Egg Harbor Road

Sewell, NJ, 08080

(856) 589-0401

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Mon - Fri: 8:00 - 5:00

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