12500 Lebanon Rd., Suite 104, Frisco, TX 75035
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Please complete the following form and answer all questions before arriving for your appointment.
Be sure to include your insurance information.We'll see you soon!
*This information is requested due to Healthcare Reform laws dictated by Congress.
Which family members had the below medical conditions? (father, mother, sibling, etc.)
Your insurance policy is a contract that exists between you and your insurance company. Ourrelationship is with you, the patient, and not the insurance company. If you havequestions aboutyour policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Please inform us at every visit of any changes to your insurance coverage.
DEDUCTIBLES & CO-INSURANCE: If you have a high deductible plan (Remaining amount greater than $250.00) OR a plan with no deductible and high out of pocket (remaining amount greater than $250.00), we may collect a $125 deposit to apply towards your deductible and coinsurance. Any remaining balance after submission to your insurance company is your responsibility.
SELF-PAY (for non-covered products and services and for patients without insurance coverage): Full payment is due at time of service. A down-payment will be required before seeing the doctor. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment
REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.
NO SHOW (failure to present for your appointment): 24 hours-notice is required for cancellation of your appointment and failure to do so will incur a $50 fee. Failure to provide 24 hours-notice for a scheduled office procedure will incur a $100 fee.
We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.
If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.
*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.
If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Greater Texas Foot & Ankle Specials has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.
Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.
Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.
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