HANSEN FOOT & ANKLE BILLING POLICY

THE HIGHLIGHTS:

• PAYMENT IS REQUIRED AT THE TIME OF SERVICE (BASED ON YOUR INSURANCE’S ALLOWABLE SCHEDULE)
• CO-PAYS AND ANY EXISTING PATIENT BALANCES ARE DUE AT CHECK-IN
• CANCELLATIONS LESS THAN 24 HOURS IN ADVANCE AND NO-SHOWS WILL INCUR A $50 FEE
• PAST DUE BALANCES OVER 60 DAYS WILL INCUR AN 18% FINANCE CHARGE.
• ACCOUNTS SENT TO COLLECTIONS WILL INCUR COLLECTIONS FEES.
• WE DO NOT ACCEPT OR BILL MEDICAID.

FOR OUR CONTRACTED INSURANCE PLANS:

We require payment at the time of service (TOS) based on your insurance company’s allowable fee schedule and your insurance group's contract with the carrier. Once your claim has been processed, your TOS payment will be applied to your balance and refunded (if applicable). Any patient’s responsibility will be due in full at your next appointment or upon receipt of the statement, whichever comes first. It is the patient’s responsibility to obtain any necessary referrals. If no referral is received by your appointment date, we will request that you either reschedule or sign a waiver and pay for your visit at the rate of self-pay services before being seen. The patient is responsible for all account balances, even with insurance benefits. We will bill your insurance as a courtesy to you, but we cannot guarantee your benefits. If your insurance company informs us of any benefits you are, or are not, entitled to, we will advise you. Any oral representation we make in good faith to you concerning your insurance is not binding on us and will not in any way or for any reason be considered a modification of this billing notice.

INSURANCE CO-PAYMENTS: Co-payments are due at check-in for your appointment. Your co-payment is determined by the insurance plan you have selected. Hansen Foot & Ankle (HFA) in no way determines the co-pay amount and is required by contract to collect the copay at the time of the visit.

MEDICARE: We will bill Medicare for you. Do not submit a claim yourself. Medicare pays 80% of their allowable fee after you have satisfied your yearly deductible amount. If you have supplemental insurance, we are required to provide Medicare with this information. In most cases Medicare will forward your claim directly to your supplemental insurance for you. Medicare does NOT pay for orthotics. Patients must meet very specific requirements for Medicare to cover foot/nail care, and it is only covered every 61 days. They also can limit the number of visits per diagnosis. It is the patient’s responsibility to pay for services not covered by Medicare. Medicare requires you to sign a waiver, when appropriate, indicating that you have been informed that Medicare may not cover certain services and that you accept financial responsibility.

MEDICAID: We DO NOT accept or bill Medicaid plans, including (but not limited to) Molina, Apple Health, Provider One, or Dual Complete. Patients with these plans accept full financial responsibility for their charges and must sign a form accepting to be seen on a self-pay basis. FAILED, CANCELLED APPOINTMENTS, AND LATE ARRIVALS: Patients who fail to attend or cancel their office visit without giving our office 24-hour notice will be charged $50.00. Patients who fail to show up or cancel their in-office procedure less than two business days before the procedure, forfeit their $100 deposit. Patients who fail to show or cancel their surgery before 30 days of scheduled surgery forfeit $300.00 of their $500.00 surgery deposit. Patients who are more than five minutes late for their scheduled appointment may be rescheduled to a different date and may be responsible for a failed cancellation fee.

METHODS OF PAYMENT/CREDIT CARD ON FILE: We accept cash, personal checks, MasterCard, Visa, Discover, and American Express. We request that a credit card be kept on file to cover any amount not covered by insurance, missed appointment charges, and all the services Hansen Foot & Ankle provides. Your credit card will be charged upon system review of the final EOB from each applicable insurance company for services provided while this agreement is in effect. Elavon, Inc., a secure credit card processor associated with U.S. Bank, will store your credit card. HFA does not store credit card numbers in our system or in our premises. You will receive receipts detailing the amount charged. You may cancel your credit card on file agreement by calling our office.

FEES:

• FORMS: The patient will be charged a $20-$40 administrative fee for us to complete Disability, FMLA, job capacities/work-related forms. We reserve the right to 48 business hours from the time of receipt to return any forms. • PAST DUE BALANCES: Balances greater than 60 days (after the first statement is delivered) will incur an 18% fee each month the balance is not paid.

• COLLECTIONS FEE: Accounts sent to collections will incur an initial fee of $10 and a fee of up to 50% of their balance added to their collections account. This is to account for the fees charged by our collections agency.

DURABLE MEDICAL EQUIPMENT (Custom Orthotics, Surgical Boot/Shoes, Cam Walkers, Orthotics, Orthotic Recovers, etc.) The patient is responsible for calling their insurance company for coverage information. As a courtesy to you, our office will attempt to call for coverage information. Any oral representation we make in good faith to you concerning your insurance is not binding on us and will not in any way or for any reason be considered a modification of this billing notice. Surgical shoes/Removable casts will be billed to your insurance, but they may or may not be a covered benefit. DME, not covered by the insurance company, is to be paid upon fabrication and dispensing. I have read and understand this policy and acknowledge full responsibility for the payment of services rendered. I authorize all payments to be made directly to Hansen Foot & Ankle for any services or supplies furnished by my doctor or the above-named Clinic and for my doctor to act as my agent to help obtain payment.

HANSEN FOOT & ANKLE PRIVACY POLICY & RELEASE OF INFORMATION

l, hereby authorize HANSEN FOOT AND ANKLE and its affiliates, its employees, and agents to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided to me and which identifies my name, address, social security number, Member ID number) to help me to resolve claims and health benefit coverage issues.I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. I understand that I can revoke this authorization by providing written notice. However, this authorization may not be revoked if its employees or agents have acted on it prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I understand that the recipient may disclose information used or disclosed pursuant to this authorization and may no longer be protected by federal or state law. I understand further that this authorization is voluntary and that I may refuse to sign it. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services. I have been advised of this practice's privacy practices, billing information policy release, and benefits policy assignment. I have also been authorized to contact the practice by mobile phone and granted the practice Medication History Authority.

Hansen Foot & Ankle

✆ Phone (appointments): 425-537-3777

✆ Phone (general inquiries): 425-537-3777

Address: 16030 Bothell Everett Highway, Suite 160, Mill Creek, WA 98012