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Consent to Treat & Financial Responsibility Agreement

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

I 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. 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

I understand that I am responsible for providing correct insurance to the Provider regarding possible third-party liability and/or insurance and if complete information is not provided my medical insurance may be billed for services. Should the third party insurance deny, or if the maximum benefits are reached, my claim(s) will be sent to my medical insurance for payment, or if none exists or is inadequate, I will be billed directly. If I decide to dispute the decision of the third party payers, I agree to make agreeable payments each month while I pursue this claim.

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 are 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.

Authorization/Pre-certification/HMO Referrals

I agree to furnish any and all 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 an authorization and you do not obtain one, you may be responsible for a higher share of cost.

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 taxpayers literally billions of dollars each year. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding Medicare. It is our policy to properly determine accurate compensation for our services in accordance 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

We have a reasonable and customary schedule of fees for all services provided from office visits to the most complicated procedures relating to injuries and disorders of the finger, hand, wrist, elbow and shoulder. If you would like further information regarding this, please let us know and we will connect you with a Financial Service representative.

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 of treat them differently because of race, color, national, origin, age, disability or sex.