INSURANCE INFORMATION

Privacy Practices

FINANCIAL INFORMATION

DISABILITY: There will be a fifteen dollar ($20) charge for each disability form and a seven to ten (7-10) BUSINESS day waiting period for all disability forms.

FAMILY MEDICAL LEAVE ACT FORMS: There is no charge but there is a seven to ten (7-10) BUSINESS day waiting period.

HANDICAP PARKING PERMITS: No charge.

MEDICAL RECORDS COPYING FEES: Payment is due prior to mailing or at the time of pick up.

• One dollar ($1) per page for the first ten (10) pages.
• Fifty cents ($.50) per page for pages eleven (11) through fifty (50).
• Twenty five cents ($.25) per page for pages fifty-one (51) and above.
• Five dollars ($5) per CD (X-Ray/MRI/Medical Records)
• Five dollars ($5) per page printed (X-Ray/MRI films)
• Requests for medical records to be provided within forty eight to seventy two (48-72) hours will be processed with an
• additional ten dollar ($10) fee.
• Please call our office for specific payment details if the following applies:
  • Medicaid patients

Authorization

PATIENT FINANCIAL RESPONSIBILITIES

FINANCIAL RESPONSIBILITY: All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with administration.
Necessary forms will be completed to file for insurance carrier payments.

ASSIGNMENT OF BENEFITS: I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize my insurance carrier(s), including Medicare, private insurance, and any other health/medical pian, to issue payments directly to New Edge Orthopedics, LLC for services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize New Edge Orthopedics, LLC: (1) release any information necessary to insurance carriers regarding my treatment; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from New Edge Orthopedics, LLC on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

Allergies

MEDICAL HISTORY: Please CHECK any conditions that you have had in the past or have currently