Patient Financial Responsibility

• Payment is expected in full at the time of service for all patients without insurance.
• Your medical services will be billed to your insurance company. Payment of all copays, deductibles, or coinsurance related to your insurance coverage is expected at the time of service. Exclusions to this policy include Medicare, except for Medicare replacement plans or managed care plans that have a copay, deductible and /or coinsurance. Convenience fees are not covered by insurance and will be the responsibility of the patient.
• Your insurance coverage is between you and your insurance company. You will need to familiarize yourself with the way your insurance company works and how it will pay for tests or procedures. It is your responsibility to know if you need pre-authorization for a procedure or testing and which facility is authorized. It is your responsibility to contact your insurance company and ask if it requires a referral to our office or to any other facility that our doctor(s) may refer you to for medical care, testing or procedure. If that is the case, you will need to contact your Primary Care Physician and have him/her fax your referral directly to our office prior to the date of your appointment.
• Sforzo | Dillingham | Stewart Orthopedics is not responsible for any out-of-pocket expenses that you may incur in relation to any medication, diagnostic testing and/or procedures.
• If we are not participating with your insurance company, you understand that payment is expected at the time of service. Any attempt to file with your insurance company will be at your discretion.
• If you have a balance less than $200 after your insurance company has paid us, we will charge the credit card you have on file without prior notice to you. If your balance is over $200 you will receive one statement with 30 days to pay before charging the card on file.
• Our business office will bill your primary and secondary insurances, however, proper billing requires that we have accurate information. A copy of your current insurance card(s) and photo ID will be made at or before the time of your initial visit. If your insurance information changes, please let the receptionist know as soon as possible. If we do not have accurate insurance information, a referral from you PCP if required, or a pre-authorization for testing if required, then the entire balance for your visit may be your responsibility.
• We require that you keep a credit card on file with us to secure any visit. Your card is entered into a secure and encrypted software which only allows us to see the last four numbers once it is entered. Less than 48 hours’ notice to cancel or reschedule an appointment will result in a fee of $200. If you do not show within 15 minutes of a scheduled appointment, you may incur a fee of $200 if we are not able to see you that day. These fees will be due before you are rescheduled. They will be charged to the credit card you have on file.
• Patients scheduled for an appointment for a Motor Vehicle Accident understand that you must inform the practice of MVA coverage when making your appointment. Prepayment may be required prior to service
• Failure to comply with the above stated requirements could result in collection activities regarding your account. Cost of attorneys and/or court fees would be your responsibility.