Financial Policy

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This is an agreement between Tri-County Orthopedic and Sports Medicine, PA., as creditor and the Patient/Debtor named on this form.

In this agreement the words "you"," your", and "yours" mean the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we", "us", and "our" refer to Tri-County Orthopedic and Sports Medicine, PA.

By executing this agreement, you are agreeing to pay for all services that are received.

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. No more than 4 statements will be sent if payment is not received.

Payments: Unless we approve other arrangements, the balance of your statement is due and payable when the statement is issued, and is past due if not paid within 30 days.

Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

Required Payments: Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for these. Any deductibles or coinsurance are also due at the time of service.

Payment options if you have no insurance:

1. You choose to pay cash, check or credit card (MasterCard, Visa or Discover) on the day that treatment is rendered.
2. When surgery is necessary, you will be counseled regarding payment arrangements.
3. We ask that elective procedures (those not considered emergent) be paid prior to the surgery being done.
4. You will receive financial counseling for an emergency procedure that must be done when payment is not available.

Payment options if you have insurance:

1. You will be asked to pay deductible, co­-pays or coinsurance amounts at the time of service. This is payable by cash, check or credit card. (MasterCard, Visa or Discover)
2. Your insurance will be called prior to surgery, and a financial counselor will attempt to contact you to discuss financial arrangements if your insurance policy benefits state that you have a coinsurance amount in which you will be responsible for.
3. Any deductibles not yet met will be due and payable by you before surgery is performed.
4. Any co-pay or coinsurance amount will be due and payable by you before surgery is performed.

Insurance: Insurance is a contract between you and your insurance company. An insurance card must be made available to us before you are seen as a patient. Even though we may estimate what your insurance will pay, it is the Insurance Company that makes the final determination of your eligibility. You are responsible for any amount not paid by the insurance less the amount written off due to a contract we may have with your insurance company. If your insurance requires a referral or authorization, you are responsible for obtaining it. Failure to obtain the referral or authorization may result in reduced payment from the insurance company.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment (signing consent) for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.

Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your debt to a collection agency, you agree to pay additional collection costs incurred from address searches, credit reports or attorney fees which can possibly equal 50% of the balance due. We may also take the claim to Small Claims Court. You agree to pay any court fees incurred in trying to collect the past due balance.

Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as the credit bureau.

Returned checks: There is a $25.00 fee for any checks returned by the bank. We prefer payment in cash on accounts with history of a returned check.

Missed appointment fee: The second time a patient does not show up on time for an appointment, or cancels with less than 24 hours notice, we have the right to charge a $20.00 fee. Extenuating circumstances will be considered. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments may be asked to transfer their records to another doctor.

Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Transferring of records: You will need to request in writing, and pay a reasonable copying fee (currently $10.00) if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Workers' Compensation: We require authorization by your workers' compensation carrier (not employer) prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient's responsibility. We cannot bill your attorney for charges incurred due to a personal injury case. You also acknowledge that we have a lien on any personal injury settlement or recovery pursuant to N.C.G.S. 44-49, et seq and you authorize your attorney or liability carrier to pay those lien amounts to us out of any settlement proceeds without further authorization from you.

Co-signature: If this or another Financial Policy is signed by another person. that co­signature remains in effect until canceled in writing. If written cancellation is received, it becomes effective with any subsequent changes.

Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. This agreement applies to previous, current or future transactions.