Intake Form

Insurance We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your Insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian. Each policy has different deductibles, co-pays, and co-insurance responsibility of the participant. Therefore, we encourage you to check your policy’s specific requirements for precertification for various treatments that may be planned for specific care. This may include, but not be limited to, MRI, bone scans, and physical therapy. We will continue to pre-certify surgeries and precertify as well as check into orthotics coverage as needed. However, a quote of benefit coverage is not a guarantee of payment. This office is not responsible for services rendered and not covered. Please contact your insurance company with any questions you may have regarding your coverage.

Co-Payments and Deductibles All co-payments must be paid at the time of service. It is ultimately the insurance policy holder’s responsibility for any and all financial aspects of services rendered. This arrangement is part of your contract with your insurance company. Failure on our part to collect copayments from patients can be considered fraud. Please help us in upholding the law by paying your copayment at each visit. Deductibles are due immediately when insurance deems patient responsible. We reserve the right to ask for payment on deductibles not met before certain treatments and surgeries.

Non-Covered Services Please be aware that some – and perhaps all – of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. Medicare does not cover routine foot care; this includes the trimming of nails and cutting of calluses if you do not meet certain systemic conditions. Your doctor will determine if you qualify at your initial evaluation. If you are a diabetic or have peripheral vascular disease or painful nails, Medicare may pay for cutting of fungus nails. Medicare has other requirements such as timely appointments with your primary care physician or your specialist who manages your diabetes or peripheral vascular disease in order for these services to be covered. This would be your responsibility to supply those dates of service at your visit for your foot care. You also must be seen within the past 6 months by your primary care physician. Completion of FMLA, Short Term Disability, Insurance Forms, etc. are not covered by your insurance and payment is due upon submission.

Proof of Insurance All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral form from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full. This payment will be held for 48 hours and will become non refundable if the proper referral is not obtained by then.

Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claims. Your insurance benefit is a contract between you and your insurance company

Coverage Changes If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

In-Office Supplies Our office supplies as a convenience to our patients over-the-counter supplies. This is an effort to eliminate going to the store to pick these items up. In order to stock these supplies, we require payment at the time of service. Insurance companies do not cover the cost of these supplies; therefore you are responsible. The office assistant will discuss a fee for the item prior to your departure. If you are unable to pay for the item at the time of service, then we kindly request you return to pick up the item when you are able to afford it.

Nonpayment Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. A re-billing charge of $10.00 per month will accrue on all accounts 30 days past due and over. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to collection with an additional charge added to cover the cost of the collection agency service fee. If this occurs you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Any checks returned with insufficient funds will be charged a processing fee.

Missed Appointments Our policy is to charge for missed or canceled appointments unless for understandable reason. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claims.

I hereby authorize my insurance company to pay and hereby assign directly to Dr. Thomas F. Vail and the Step Alive Foot & Ankle Center (SAFAC) all professional and medical benefits through the means off electronic funds transfer(s) *EFT) or by check(s) made payable to and mailed to SAFAC, if any, otherwise payable to me for his services. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits when received by and paid to Dr. Thomas F. Vail will be credited to my account, in accordance with the above said assignment.

Electronic Signature (*)