Assignment of Benefits – Medical Facility
I do hereby transfer, assign, and convey all my rights, title and interest in all medical benefits provided by any contract or policy of insurance under which I may be insured. I direct that all benefits be paid directly to Hand to Shoulder Center of Wisconsin and/or Woodland Surgery Center (collectively “Provider”) for payment of services rendered. I agree to pay the Provider any remaining balance after insurance payments or denial of coverage under said contracts or policies. As the Provider, we are committed to providing excellent service to our patients. If you have billing questions, we encourage you to call the office at (920) 730-8833 during office hours from 8:00 A.M. – 5:00 P.M., Monday thru Friday.
Medical Records
authorize that any medical, mental health, HIV testing and status, and/or substance abuse information be released in accordance with Health Insurance Portability and Accountability Act (HIPAA) guidelines and Wisconsin State Statutes. This may include electronic transfer of data with external entities. I understand and agree that no liability of any nature shall attach to any person, physician, surgeon, or employee of the Provider, following such authorized release of information.
Prescription Refills
Provider will not provide narcotic prescription refills between the hours of 5:00 P.M. and 8:00 A.M. weekdays or on weekends. If you need to have your prescription refilled, please notify your physician during your visit or call during business hours. Calls received late in the day may not be addressed until the following day. As a patient, I understand that prescription refills will not be provided during non-business hours..
Third Party Payers
If you receive treatment as a result of a third-party liability injury (ex: motor vehicle accidents, premises liability or any other liability) we do NOT bill any third party. We will submit a claim to your personal health insurance carrier on your behalf. You may receive an accident questionnaire to be completed by you. We will provide the patient with any itemized bills to assist in obtaining reimbursement from third party.
Worker’s Compensation Claims
In the event of a Worker’s Compensation claim, I understand I am responsible for providing the correct insurance information to the Provider and that if complete information is not provided, I may be balance-billed for services. All medical information may be furnished to the carrier and/or employer with or without written consent from the patient according to the Wisconsin Worker’s Compensation Action, Sec. 102.12(2). I further understand that my opinion and/or Doctor’s diagnosis does not necessarily insure payment of my claims by the Worker’s Compensation carrier. Should Worker’s Compensation deny my claims, I agree to pay all charges incurred by the Provider. If I decide to dispute the decision of the Worker’s Compensation carrier, I agree to enter into acceptable payment arrangements with Provider while I pursue this claim.
Uninsured
Patient without insurance will be asked to meet with a Financial Service representative to establish a payment arrangement for the balance of your fees that is acceptable to Provider.
Patient is a Minor
As the parent/guardian, by signing this agreement you authorize and give consent to the Provider to furnish medical care and treatment to the minor patient. All charges for services provided by the Provider to the minor patient are the responsibility of the parent/guardian authorizing treatment.
Authorization/Pre-certification/HMO Referrals
I agree to furnish all accurate and up-to-date personal and insurance information required by the Provider for purposes of filing claims, pre-certification, authorization or any other purpose. If your health insurance requires an authorization to be seen by a specialist, it is the policy of the Provider and Managed Health Care plans that the patient is responsible for obtaining authorization for all visits, Worker’s Compensation or otherwise. If your policy requires authorization and you do not obtain one, you may be responsible for a higher share of the cost. If you supply new insurance information after the correct insurance’s window of timely filing, we will attempt to submit claims to insurance but if denied for timely filing, it is your responsibility.
Outside Referrals
I understand that all referrals for diagnostic testing, treatment and/or other services not offered by this provider, are offered at my discretion. Payment of said services is my sole responsibility. Lab work, anesthesiologist and hospital fees are billed separately by offices outside the Hand to Shoulder Center of Wisconsin and Woodland Surgery Center.
Medicare Authorization and Assignment
If I am a Medicare patient, I allow the Provider to submit Medicare claims in my behalf without signing a Medicare form at each visit. This authorization extends for a period of two (2) years, or for as long as I remain a patient of the Provider. Compliance Assurance Notification for Medicare Patients: Healthcare fraud and abuse have been identified as a national problem costing taxpayer literally billions of dollars each year. We want you to know that all our employees, managers and doctors continually undergo training so that they may understand and comply with the governmental rules, laws and regulations. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any Medicare service or billing errors.
Fees
If I am a Medicare patient, I allow the Provider to submit Medicare claims in my behalf without signing a Medicare form at each visit. This authorization extends for a period of two (2) years, or for as long as I remain a patient of the Provider. Compliance Assurance Notification for Medicare Patients: Healthcare fraud and abuse have been identified as a national problem costing taxpayer literally billions of dollars each year. We want you to know that all our employees, managers and doctors continually undergo training so that they may understand and comply with the governmental rules, laws and regulations. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any Medicare service or billing errors.
Physician and Therapy Visits
Your visit will include an examination and discussion of a treatment plan recommended for you. There is a fee for these services and for follow-up visits.
Patient Valuables
All parties are advised that the Provider is not responsible for any valuables brought onto the premises. You are strongly urged not to bring such items with you or to keep personal items of significant value in your possession at all times.
Financial Responsibility/Delinquent Accounts
I understand that I am responsible for payment of all services rendered to me by the Provider and that any and all fees not paid by my insurance are my sole financial responsibility. The Provider reserves the right to impose a late charge of 1% per month on any accounts not paid within 30 days. I agree to pay all costs of collection for the Provider including attorney fees in the event that my account is placed in legal collection. I understand and agree that I am responsible for any part of the fees for my treatment and services provided by Provider. I also understand and agree that services provided by other providers (including charges for surgeons, anesthesiologists, or other treating physicians) at our facility may be billed separately and are my financial responsibility.
Non-Sufficient Funds (NSF) Checks
A $25 charge will be assessed for all returned checks. NSF checks not redeemed within ten (10) days of notification will be subject to legal action.
Language Assistance Services/Notice of Nondiscrimination
Provider complies with applicable Federal Civil Rights laws and does not discriminate on the basis of race, color, national origin, disability, or sex. Provider does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Please visit our website at www.handtoshoulderwisconsin.com for more information on free sign language services and free language interpreter services for those whose primary language is not English.
Communicable Disease:
At any time or in any place, the risk of exposure to communicable disease may occur. Reasonable measures are in place aimed at reducing the spread of disease. There is an inherent risk of becoming infected and possibly developing complications.