Thank you for choosing our office to provide you with medical care. We are committed to serving you with skill and high quality care. The medical services provided by our office are services you have elected to receive and may create a financial responsibility on your part.

 

 1. INSURANCE

We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

 

2. MEDICARE

We are a participating Medicare provider. Medicare as well as your secondary insurance (if any) will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not yet been met. You are also responsible for any copayments, which are usually 20% of the allowed amount for an item or service.

 

3. SECONDARY INSURANCE

Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance company.

 

4. COPAYMENTS AND DEDUCTIBLES

All co-payments and deductibles must be paid at the time of service. We accept the following payment methods: VISA/MasterCard/Discover/American Express.

 

5. ORTHOTICS

Our office can design and create custom orthotics that are tailored to your particular foot disorder or condition. Many insurances cover this service but it is not uniform. Because of the time and cost incurred by our office to provide orthotics, we must charge a nonrefundable 50% deposit at time of order with the remainder due upon receipt of the orthotics.

 

6. SELF-PAY

Payment in full is due at the time of service if you do not have health insurance. For your convenience we accept the CareCredit healthcare card. Applying is fast, easy and secure.

 

7. NON-COVERED SERVICES

Please be aware that some of the services you receive may not be covered by Medicare or other insurers. You are responsible for payment of these services.

 

8. DOCUMENTATION

A fee of $25.00 will be applied for all documents that require completion by the physician. Additionally, there will be a fee for a copy of your medical records and X-Ray images.

 

9. REFERRALS/AUTHORIZATIONS

We are required to follow the guidelines of your managed care plan, which mandates that when you visit a specialist such as ours, you must have a referral from your primary care physician prior to seeking specialty care, if required. Therefore, you are financially responsible for the services received, unless your referral is presented at the time of the visit. If you do not have a referral from your primary care physician at the time of the visit, you will be financially responsible for all services received due in full upon completion of the visit. Full credit will be given if a referral is presented to our office within 48 hours of this visit. You will also be given the option to reschedule your appointment.

 

10. CLAIM SUBMISSION

We will submit your claim to your insurance company, however your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Any unpaid balance not covered by your insurance is your responsibility.

 

11. PATIENT BILLING

YOUR BALANCE MUST BE PAID IN FULL, PRIOR TO CONTINUING VISITS. You will be sent three notices regarding your outstanding balance after payment and/or explanation of benefits (EOB) is received from your insurance company/companies. After the third notice, your account will be forwarded to collec-tions. Please notify the billing office if you are unable to pay your bill in full. Payment arrangements may be available although interest will accrue at a rate of 15% monthly. We accept the following payment methods: VISA/ MasterCard/Discover/American Express.

An additional $25.00 will be added to your statement if the check is returned for insufficient funds. In the event that your insurance company sends payment directly to you, it should be forwarded to our office to be applied to your balance. In the event, you do not show up for your appointment, and you failed to call the office to cancel or reschedule, you are defined as a “no-show” and will be billed $75.00.

Thank you for understanding our financial/payment policy. Please let us know if you have any questions or concerns.

 

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I have read the above policy regarding my financial responsibility to RNV Podiatry for medical services provided. I agree to pay RNV Podiatry any balance not covered by my insurance:

Any information disclosed in your records will remain confidential and will not be used for any other reason except in pro-viding quality care and treatment as well as to submit your claim to your insurance company and contact you as needed.

PATIENT ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICES

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices, and that I have (or had the opportunity to read if I so chose) and understand the Notice and agree to it’s terms.

 

ASSIGNMENT OF BENEFITS

I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to RNV Podiatry all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions.I understand that it is my responsibility to inform the doctor’s office if there is a change in my health insurance information. 

 

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NOTICE OF PRIVACY PRACTICES

I have been presented with a copy of RNV Podiatry, Notice of Privacy Practices detailing how my information may be used and disclosed as permitted under federal and state law. I understand the content of the notice.

 

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I certify that the information on the history form is true and correct to the best of my knowledge. I hereby consent and give my permission to the doctor to administer and perform such procedures, including therapeutic and diagnostic injections, as may be deemed necessary in the diagnosis and/or treatment of my feet or ankles.

 

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I understand that in order to disclose my Protected Health Information, RNV Podiatry must have my consent. Therefore, I authorize RNV Podiatry to disclose my Protected Health Information as described on this form, to the recipients listed below: 

Name(s) of the person(s) authorize to obtain the above-mentioned information. Example: physician other than your referring doctor, family members, other specified person(s).

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Dr. Rachel Verville (RNV Podiatry), including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

Please click to submit your form securely. A copy of this will be sent to the e-mail listed above.