CAROLINA SPORTS MEDICINE & ORTHOPAEDIC CLINIC

FINANCIAL POLICIES AND AUTHORIZATIONS

Thank you for the trust you have placed in me and my staff to care for your orthopaedic needs. My office is acutely aware of the escalating costs of medical care and insurance, and makes every attempt to maintain fees which are fair and reasonable, considering the professional services performed. I believe communication regarding my financial policies is critical, so I have listed them here for your observance.

My basic practice policy is “Payment is expected at the time of service.” Insurance will be filed in the following cases, when your deductible has been satisfied:

  1. You have a managed care contract with which we participate, AND you have your referral form.
  2. You are a member of a PPO with which I participate.
  3. You have Medicare and/or Medicaid insurance.
  4. You have surgery performed at the clinic or hospital.
  5. You have a Worker’s Compensation case.

Payment of copay and/or deductible is due at the time services are performed.

As a courtesy to my patients, I accept both MasterCard and Visa, at no charge.

For my patients requiring medical or surgical procedures who are not covered by any insurance plan, I require a deposit equal to 50% of the estimated fees before the performance of any procedure. For your convenience, I will schedule a meeting with our Patient Advocate to discuss any questions you may have.

At times, medical credit may be extended to those of my patients who do not have insurance or who have a balance after insurance over $100.00. Medical credit is provided to patients who otherwise might not be financially able to receive proper medical attention. A payment plan must be arranged with my billing staff at the time of your first office visit or after insurance has paid the maximum benefit.

If your account is placed in the hands of a collection agency, collected by an attorney, or through legal proceedings, all associated collection expenses, including a collection fee will be added to the amount owed on your account.

I welcome any questions or comments you may have. Thank you for taking time to read and understand these policies.

DR. FRANK F. PHILLIPS

I have read and understand the financial policies described above and agree to be fully responsible for payment of medical services performed on my behalf, or to those persons who I am responsible for, by Carolina Sports Medicine & Orthopaedic Clinic.

I authorize payment of medical benefits, including Medicare, to this practice for the services rendered. I also authorize the release of any medical or other information necessary to process insurance claims and the release of any information acquired in the course of my examination and treatment at the clinic.

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Signature of Patient or Guardian Date