General Patient Information
Our staff will ask you to fill out a patient information form if you have not done this.
These questions are a necessary part of the examination so the doctor can obtain essential data about you. Your address and phone number are needed in case the doctor needs to get in touch with you. Information concerning occupation, age, etc., is likewise important because it has a bearing upon your health and physical status. If you have insurance claims made out by this office, all of these items are necessary to complete the forms. All information given to us is strictly confidential.
After the doctor has examined you and given you the proper instructions, please present the charge slip to the receptionist at the check out desk. She will give you your next appointment and discuss the charges with you. Please refer to the enclosed credit policy for further information
Our Physicians make every effort to stay on schedule. However, in our specialty we often have emergencies that require immediate treatment. If we are delayed, we will try to notify you as soon as possible of the delay.
If your insurance company requires pre-admission authorization for hospitalization and/or surgery, it is your responsibility to notify us and secure the necessary forms.
Please bring all x-rays you have had taken relating to your complaint, (for example: kneex-rays for a knee exam). This does include MRI, CT and bone scans as well as regular x-rays.
Call the doctor’s office or hospital where you had your x-rays taken, and they will loan them to you or they will send them to us in advance.
If you have any questions, call the x-ray department at Northwest Iowa Bone, Joint & Sports Surgeons.
Credit Policy Information
The following credit policies and instructions were made after careful dilberation and are necessary if a good doctor-patient relationship is to be maintained. They must be followed by all the patients if we are to continue to provide the medical care and service you and your family want and need. All accounts (self pay, insurance, auto accidents, etc) that are not paid according to these policies will be considered delinquent and necessary action will have to be initiated. The clinic does not hold another party responsible for payment of service you receive. At all times the amount due is the responsibility of the patient. Please let us know if you have any questions regarding these policies or if any of these policies will create an undue hardship for you.
Office charges: Office charges are due and payable at the time of service.
Hospital/Outpatient charges: Thirty days open credit is extended to all patients with a good credit rating. The account is due in full at the end of this period unless permission is received from our office to pay over a longer period of time. You may call or write for this permission. Upon request, special consideration may be extended in the event of prolonged illness, unemployment, or other unusual circumstances. To avoid misunderstandings, we invite you to discuss your financial problems early.
Office Charges: We will be happy to submit the office charges to your personal insurance company. You are responsible to provide us with your insurance card with policy numbers and address of the insurance company. All office charges are due and payable within 30 days of billing.
Hospital/Outpatient Charges – Credit is extended to all patients with good credit rating for hospitalization/outpatient charges. NW IA Bone, Etc. cannot except the responsibility for collecting your insurance claim or negotiating a settlement on a disputed claim. You are responsible for payment of your account within the limits of our credit policy. Charges for our services are billed to you as the patient. You will be held personally responsible for your account until the account is paid in full. As a courtesy, we will be happy to file the necessary insurance forms with your company, however it is your responsibility to supply us with the insurance information and signed assignment of benefits. We expect payment within 30 days of filing the insurance claim. If payment comes within the specified time and there is an insurance difference, you will be billed for that balance.
If payment is delayed for any reason, we will look directly to you, the patient, for payment according to the credit policy.
If we receive a check from your insurance company after your account has been paid in full, or if the check from your insurance company leaves a credit balance, we will promptly issue you a refund check.
If you are injured in an automobile, motorcycle or other personal injury accident the circumstances being such that you believe another party is responsible (liability claim), please remember that since you are the one receiving treatment, the Clinic can only look to you for payment. It is our policy that payment for your treatment be on a current basis. At the time of settlement of your claim, you will be reimbursed by your attorney or insurance company. We will not hold your account open during the period of litigation. We expect payment promptly.
There are many managed care insurance plans (HMO/PPO) in the marketplace today. While we do participate in certain plans, insurance companies and employers frequently change networks and provider relationships. The participating provider lists you have may not be current.
Please check with your insurance company to obtain your most current benefit information for services provided by our office.
If your on-the-job injury has been verified as a Worker’s Compensation claim, we will bill your employer or insurance company. We attempt to preauthorize all work comp claims prior to the first appointment. If we are unable to obtain authorization and you do not bring written authorization with you the day of your first appointment, your account will be treated as a self-pay and we will ask that you pay for the visit at the time of service. If you have questions about your worker’s comp authorization, please call our office.
The Health Information Department at Northwest Iowa Bone, Joint and Sports Surgeons will be happy to assist you in the completion of your disability form(s) or any Request of Information form(s). There is a fee for each form due at the time of your request to fill out your disability form(s) with the completed form being forwarded as per your instructions in approximately 2 weeks.
This office has voluntarily elected to participate in the Medicare Assignment Program. What this means to our patients is that we accept all responsibility of filing Medicare claims and payments are made directly to our office.
Traditional Medicare Only
If you do not carry supplemental insurance, after we receive the Medicare payment, you will be billed for the deductible and the 20% allowed by Medicare. Payment is due when billed.
Traditional Medicare & Supplement Insurance
If you do carry supplemental insurance we will submit the claim as soon as the Medicare payment is received. You are responsible to pay the deductible and the 20% allowed by Medicare if your co-insurance does not pay within the limits of our credit policy.
Medicare & Medicaid
Medicare and Medicad will be submitted automatically. You must bring your eligibility card with you at the time of service. This card must verify that you are eligible for the month you are receiving treatment.
You must bring your eligibility card with you each visit. The card must show that coverage is valid for the month you are being treated. If you do not present this card at the time of service, you will be expected to pay cash for that day’s service. We participate in Iowa Medicaid/Medipass programs. Other out-of-state recipients will be responsible to pay their own account at the time of service.
1. Your insurance policy is a contract between you and your insurance company. Therefore, the Clinic cannot bill or charge your insurance company for services rendered to you, but can only submit a claim for the charges incurred.
2. We cannot guarantee to you that your insurance will pay your claim. It is very important that you understand completely the provision of your insurance policy.
3. If your insurance company fails to pay your claim, they should explain to you why
it was rejected. If you are dissatisfied with their rejection, or the amount they pay,
it is your responsibility to take the matter up directly with your insurance company. Please do not penalize the Clinic, or jeopardize your credit rating by not paying your bill because of this dissatisfaction.
4. If you have ever had an account from this office turned over to a collection agency or involved in a Bankruptcy Case, we must insist on cash payment at the time of service without exception.