FINANCIAL POLICY Texas Orthopaedic & Sports

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FINANCIAL POLICY Texas Orthopaedic & Sports Medicine is committed to providing you with quality patient care. Your clear understanding of our Financial Policy is important to our professional relationship. The following information is being provided to address the questions most frequently asked by our patients. If you have any questions about our fees, financial policy, or your financial responsibility, please let us know. ACCOUNT RESPONSIBILITY You are responsible for all charges incurred on your account. It is also your responsibility to make sure all information on your account is current and accurate. Accounts with incorrect information can cause payment delays. Please contact our office if there are any changes in your patient information. INSURANCE BILLING As a courtesy to our patients, we will bill your medical insurance carrier and your secondary carrier if one is provided. TOSM contracts with many different companies. Due to the different plans available, it is impossible for us to know if your plan is included. You will need to check with your insurance company in advance. Please keep in mind that your insurance may not cover or pay all charges incurred and any unpaid balance after your insurance has paid is the responsibility of the patient. CO-PAYs, DEDUCTIBLES AND CO-INSURANCE All co-pays are due at the time of service and your insurance plan may change your co-pay periodically. It is the patient’s responsibility to know what their co-pay is (regardless of what is printed on your insurance card), as well as deductible and co-insurance amounts. Full payment is expected at the time services are rendered if you do not have medical insurance. UNPAID ACCOUNTS PAST 90 DAYS Unpaid accounts will be turned over to AMERICAN CREDIT BUREAU and all charges incurred must be paid in full before any additional service is rendered. METHODS OF PAYMENT Texas Orthopaedic & Sports Medicine accepts cash, personal checks, money orders, Visa, MasterCard, American Express and Discover Card. Payments can be made in person, by mail, or by telephone when paying by credit card.



I hereby authorize Texas Orthopaedic & Sports Medicine to furnish information to the insurance carriers concerning my illness and treatment. I hereby assign to the physician(s) all reimbursement for medical services rendered. I understand that I am responsible for all charges not covered by insurance. I have read, understand and agree to the terms of Texas Orthopaedic & Sports Medicine's Financial Policy. _________________________________ _____________________________________ Signature of Patient or Legal Guardian Date _________________________________ _____________________________________ Print Name Print Patient Name If Patient Is a Minor