We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial policies as an essential element of your care and treatment. As our patient you are responsible for all authorization/referrals needed to seek treatment in this office. Payment for office services are due at the time of service. We will accept VISA, MASTER CARD, or CASH. Your insurance company is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period we will have to look to you for payment. We have made prior arrangements with insurers and other health plans to accept and assign benefits. We will bill those plans with which we have an agreement and will only require you to pay the copay/coinsurance/deductible at the time of service. If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatments are due at the time of service. All health plans are not the same and do not cover the same services. In the event your health care plan determines a service to be “NOT COVERED,” or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however; you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. Durable Medical Equipment (DME) to include but not limited to: Custom Orthotics, Custom and Non Custom Ankle braces, and Cast Boots You must inform the office of all-insurance changes and authorization referral requirements. In the event the office is not informed, you will be responsible for any charges denied. For most services provided in the hospital we will bill your health plan. Any balance due is your responsibility. There are certain elective surgical procedures that we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery. A $15.00 Administration will be assessed by 45 days or more. Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due at this office. All accounts over 90 days past due will be turned over to collections and a 30% collection fee will be assessed. There is a service fee of $30.00 for all returned checks. Your insurance company does not cover this fee. Fee for broken appointments: Broken appointments will incur a charge of $60.00 unless 24 hours notice is given. The office must be notified by 3 pm the day before an appointment in order to not incur a broken appointment fee. If the appointment is rescheduled the fee will be $30.00 but the rescheduled appointment must be kept. A fee of $100.00 will incur for surgery cancellations with the exception of a doctor’s note. This is a fee that the patient (not insurance) is responsible. This charge may be waived in certain circumstances by management only. Assignment of Benefits: I understand that I am responsible for payment in full of charges. I authorize payment of benefits from my insurance to be payed directly to Aaron Ben Pearl D.P.M. I also authorize Aaron Ben Pearl D.P.M. to release my insurance company any and all information necessary for the processing of insurance claims. Name First Last PhoneAgreement I agree to the financial policy.SignatureDate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.