Financial Policy

Thank you for choosing Wellington Orthopedic Institute, LLC as your health care provider. We are committed to your health and well-being and want your care and treatment to be successful. Please understand that payment of your account is considered an integral part of your treatment.

We ask that all responsible parties read and sign this policy prior to seeing the physician. This policy is offered to develop and sustain a continued professional and pleasant relationship. Our billing department is available to discuss our fees and this policy with you.

We are a specialist health care provider; therefore specialist co-payments and deductibles are due at the time of service. Our providers accept most, but not all, insurance plans. Please check with our staff if you are unsure whether we accept your plan. If your insurance plan is one we do not accept, you may still be seen and treated by providers at Wellington Orthopedic Institute, LLC as out-of-network. You may be responsible for the full charges of services rendered, or you may need to pay out-of-network cost sharing under your health plan. Please see the out-of-network consent and estimate of services.

Uninsured (self-pay): Payment in full is expected at the time of service unless arrangements have been made with our billing department prior to services being rendered.

We accept cash, check, American Express, Visa, Mastercard, Discover, and CareCredit.

Please read the following carefully:

1. We will ask for your insurance card during your visit. Please be prepared to present it at check-in.
2. Payments for all services, including unpaid balances, deductibles, co-payments, or other non-covered services as set by your insurance carrier, are due at the time of service. Unpaid balances may be subject to collection placement and collection fees. A $25 service fee will be assessed for returned checks, regardless of the reason.
3. Your insurance policy is a predetermined agreement between you, your employer, and the insurance company. We are not a party to that agreement. Our relationship is with you, not your insurance company. As your provider we will provide information to facilitate claim processing. Please understand that we may not know whether your insurance will cover your services until the claim has been submitted. While we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. Any laboratory test that requires an outside lab to perform will be billed by that company.
4. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, then after such default and upon referral to a collection agency or attorney by Wellington Orthopedic Institute, LLC, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.

Financial Agreement

I have read, understand, and agree to this financial policy. In the event of non-payment by my insurance carrier for whatever reason, I understand that I am responsible for payment of the balance owed, inclusive of all court costs and attorney fees of 30%. I authorize the release of any medical or other information necessary to process medical claims. I authorize payment of medical benefits to Wellington Orthopedic Institute, LLC.

Notice of Privacy Practices — Written Acknowledgment

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in that notice, the terms of the notice may change. If we change our notice, you may request a revised copy.

By checking the acknowledgment below, I confirm that I have been provided access to a copy of Wellington Orthopedic Institute, LLC’s Notice of Privacy Practices for review.

This acknowledgment will remain in effect until otherwise revoked by me in writing. I understand that I may ask questions of the Privacy Officer if I do not understand any information contained in the Notice of Privacy Practices.

Consent to Treatment and Authorization for Claims

I hereby authorize and consent to all examination and treatment necessary for the care of the patient named on this form. I consent to all procedures incident to such treatment that are deemed necessary by the provider. I authorize the release of medical information to process my claims, and I authorize Wellington Orthopedic Institute, LLC to receive insurance payment directly for services rendered.

Release of Information to Individuals You Designate

I consent to the release of information regarding my medical history, current medical condition, current medical treatment, and patient account information to the individuals I list below. If you do not want any information released, leave these entries blank.