I understand that I am responsible for all charges at the time of service. I understand that it is my responsibility to provide LROS with current, accurate billing information at the time of check-in and to notify the office of any changes. LROS may submit claim information to my insurance company for processing but does so only as a courtesy for me. LROS will try and verify that the providers are in-network with your insurance company however I understand that I am ultimately responsible for knowing my plan and knowing what providers are in-network. I am responsible to pay all charges before my insurance company pays or determines the amount I owe after insurance regardless of any billing mistakes or disputes.
I understand that if I do not have insurance I am required to pay 100% of my responsibility in advanced for services that will be rendered. This includes but is not limited to; office-visits, x-rays, procedures and surgery.
I understand that it is my responsibility to know my specialist co pay and pay it on the day services are rendered because it is a contractual agreement with my health care plan.
I understand that if I present an insufficient funds check for payment on my account, I will be charged a fee by this office and will be required to rectify my account by paying with cash, money order or credit card.
I understand that Liljenquist & Redd Orthopedic Surgery will verify my insurance eligibility, deductible and coinsurance amounts prior to any elective surgery that I may have. I understand that receipt of a prior authorization is not a guarantee of payment, and I will be responsible for any bills not paid by my insurance carrier. I understand that it is the policy of Liljenquist & Redd Orthopedic Surgery to collect at least 50% of the estimated deductible and co-insurance amount prior to surgery, unless other arrangements are made prior to surgery. I further understand that the fee I am quoted is an estimate based on the anticipated surgery to be performed and the current information made available by my insurance carrier.
I understand that I have a financial obligation and responsibility to pay all deductible and co-insurance amounts as promptly as possible following the rendering of services. I understand that I will be provided two (2) statements for any balance due after insurance payment. I further understand that if no payment is made following receipt of the second statement that my account may be sent to a collection service for further legal action. I understand that I will be responsible for any collection, interest, or legal expenses associated with these collection actions. I understand that if sent to collections there will be a 35% fee added to my balance.
I understand that if I cannot pay my balance in full then an auto-pay payment plan will be arranged. I understand that the only way a payment plan can be made is by auto-pay with a credit or debit card securely on file.
Liljenquist & Redd Orthopedic Surgery charges $20 for completion of patient forms such as; FMLA and disability paperwork. Payment is to be made before the completion and return of requested documents.
My signature below confirms that I have read these billing policies and understand my financial obligations as pertains to Liljenquist & Redd Orthopedic Surgery, Joseph R. Liljenquist, M.D and Brigham B. Redd, M.D.
X______________________________ Print Name: _______________________Date ________ Relationship__________
