CONSENT FOR TREATMENT

CANCELLATION POLICY

My signature at the conclusion of this Agreement confirms that I give CONSENT TO TREATMENTas described above and that I have read and agree to comply with The Center for Morton’s Neuroma, LLC’sCANCELLATION POLICY.

FINANCIAL POLICY / ASSIGNMENT OF BENEFITS

Payment is always PRIOR to service: We accept cash,Visa or MasterCard. Returned check fee is $40. If you do not have payment for your copay, deductible, co-insurance or balance due at the time of the visit, you may be asked to reschedule your appointmentand no show fees will apply. If needed, please ask about a payment plan. (By law, your insurer requires us to collect 100% of your financial responsibility under your contract. We are not permitted to waive or otherwise reduce this obligation on your behalf.) If you receive a statement, payment is due at the time you receive the statement.

• Payments. Your share of co-pays, deductibles, and co-insurance are your responsibility, and payment is due at the time of service. We ask that you leave a credit card on file to pay your balance once your claim has been adjudicated by your insurance company. A finance charge of up to 5.0% per month will be charged for nonpayment of your account. See Collections below.
• A valid picture ID, your insurance card(s) and a credit card are required at the time of your office visit.Please confirm your health insurance information at the time of scheduling.
• For Medicare NGS Insurance. It is your responsibility to notify the staff of any changes in your address, phone number and/or insurance plan, and provide a current up-to-date insurance card at each visit. Failure to do so may cause your insurance claim to be rejected, thus making it your responsibility to pay for the total cost of the visit. Please review your benefit listing summary that you received from your insurance company to understand your coverage.
• Participating Insurances. We participate with Medicare NGS insurance only.
• Self-Pay. For all patients, except Medicare NGS,you are considered self-pay. Payment in full is required at the time of each service. Fees are available upon request.
• Secondary and Tertiary Insurances for Medicare NGS: If applicable, secondary and tertiary insurance claims will be filed once. If payment or denial has not been received within 30 days of filing, you will be responsible for payment in full. You must make us aware of any secondary and tertiary coverage at the time of your appointment.
• Account Balances and Collection Procedures. You're responsible for payment of your account at the time of service. Your balance is due in full unless a previous payment agreement has been made. We reserve the right to reschedule or deny a future appointment on delinquent accounts.
• Additional Charges/Policies
  • Payment Challenges. Services that we provide are not eligible for payment challenges after services are rendered.
  • Release of Medical Records: The fee for a medical record is $35.00. Please allow 14 business days for processing the medical records before calling to check the status of your request. Additional postage will be charged unless records are picked up from the office.
  • After Hours Call: After hours paging is for Emergencies only. Non-emergency calls may result in a charge of $45.00.
• Assignment of benefits. I certify that I (or my dependent(s)) have active and valid insurance coverage and have supplied The Center for Morton’s Neuroma, LLCwith the up-to-date and correct insurance identification card(s) as well as all necessary information regarding the guarantor of the insurance policy(ies) and the subscriber as is required to submit medical claims for reimbursement. I understand that failure to provide updates to any of the information supplied may result in denial of payment(s) to The Center for Morton’s Neuroma, LLC. I understand that resubmitted claims with corrected updated information may still be denied due to the fact that the corrected information was not supplied in a timely fashion.

  I, the undersigned Patient assign all rights and benefits of insurance of any and all applicable medical payments and/or other insurance (including legal suits if applicable) to The Center for Morton’s Neuroma, LLCand/or its affiliates and subsidiaries for services and/or supplies to the undersigned Patient and Worker’s Compensation or other insurance coverage under my policy, in accordance with Mass. General Laws Ch. 90. Sec. 34M.

  I hereby instruct the insurance carrier that in the event my medical benefits are disputed for any reason, (including medical relatedness, reasonableness and/or necessity) or any take back by the insurance carrier, that the amount of benefits claimed by The Center for Morton’s Neuroma, LLCis to be set aside and not disbursed until the dispute is fully resolved.

  I understand that it is my responsibility to pay The Center for Morton’s Neuroma, LLCfor those medical services rendered to me or my dependent(s). I understand that I am financially responsible and I personally guarantee payment for all charges whether or not paid by insurance.

• Collections. If no payment is received within the 3rd statement cycle (approximately 90 days from my date of service), my account will be considered delinquent and will be referred to an outside collection agency or the local court system. Referral to outside collections results in a service charge of $35 and may damage my credit rating. (Please contact our Billing Department to work out payment arrangements so that we can avoid this step.)

  I understand that if my account is referred to an outside collection agency or taken to court, I agree to pay any collection fees, reasonable legal fees, court costs, and other expenses incurred as a result of said collection or court date. Further, I understand that a late payment charge (5.0%) will be applied monthly to any balance carried forward.

I certify that the information I have reported with regard to my insurance coverage is correct and I hereby authorize The Center for Morton’s Neuroma, LLC, the release of any information relating to any claim for benefits, in order to process any claim for benefits and to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I am irrevocably consenting to allow The Center for Morton’s Neuroma, LLCto use and disclose my protected health information to any Credit Card Entity, Bank, or Financing Company when they request such information to process an account and assist with payment.I acknowledge that I will not challenge any payments (including credit, debit, or financing card payments) once the services are provided. If correct insurance is not given or if there is a lapse in coverage or a change to my health insurance policy, I am financially responsible for payment for all charges.

By signing below, I also acknowledge the receipt of The Center for Morton’s Neuroma’sNotice of Privacy Practices which provides me with detailed information about how they may use and disclose my protected health information for the purposes of treatment, payment, and health care operations. I can also obtain a copy at https://www.mortonsneuroma.com/privacy-policy.

My signature at the conclusion of this Agreement confirms that I have read and fully understand the FINANCIAL POLICYand ASSIGNMENT OF BENEFITS POLICYabove and I acknowledge the receipt of The Center for Morton’s Neuroma, LLCNOTICE OF PRIVACY PRACTICES.

COMMUNICATION and YOUR CARE

MEDIATION

AGREEMENT TO RECEIVE ELECTRONIC COMMUNICATION

• I agree that the healthcare provider and office may communicate with me electronically at my email address.
• I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
• I am responsible for providing the healthcare provider and office any updates to my email address.
• I can withdraw my consent to electronic communications by calling this office.

My signature below confirms I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I do hereby CONSENT TO TREATMENT of my condition/s by the staff of The Center for Morton’s Neuromaas specified above: