We are happy that you selected TONY MARTIN LIMB AND BRACE, LLC for your healthcare needs and look forward to working with you. To help you understand your financial responsibilities to your medical care, we would like to briefly outline our financial policies.

    Patients are expected to provide identification and if insured, a current insurance card(s) at time of service. Patients are financially responsible for all services provided and are expected to pay for services at time of service, including any past due balance from a prior date of service. If the patient is a minor child, the parent or other adult accompanying the child will be financially responsible regardless of legal guardianship. Returned checks will be subject to fees.

    Medicare- The office will bill the Medicare intermediary. Patients are responsible for the following:

    •Annual Medicare deductible
    •All applicable co-pays of the allowed charge
    •Any non-covered services
    •Any covered service ordered by the physician which does not meet Medicare's medical necessity and for which the beneficiary signed an Advanced Beneficiary Notice (ABN)

    Medicare Supplemental and Secondary Insurances: The Practice will bill both Medicare and secondary Insurances.

    Patients must provide the Practice with a current Medicaid card at each visit. Medicaid patients are responsible for applicable co-pays and for all non-covered services. Medicaid patients are responsible for securing necessary referrals from their primary care physicians.

    Commercial Insurance Plans: Patients are responsible for payment of the co-pay, co-insurance and/or deductible, or non-covered amounts at the time of service as well as for any charges for which the patient failed to secure prior authorization, if authorization is necessary.
    Insurance is filed as a courtesy and benefits are authorized to be paid directly to the Practice. Patients are responsible for the balance in full if not paid by the insurance within 30 days.

    Patients are responsible for payment in full at the time of services for all services rendered.

    Employer authorization must be obtained before treatment is rendered or the patient will be responsible for payment in full at the time of services for all services rendered. Once authorized, patients are not responsible for any charges unless the workers compensation case is dismissed or denied.

    The patient is responsible for the balance in full at the time of service. Any settlement you receive from your insurance company or other third party will be handled by you, your insurance company, and/or your attorney.

    If the patient presents with an out of state HMO/PPO insurance card, we will need to verify the patient's benefits for out-of-state or out-of-network benefits. The patient may be required to make payment in full or pay any co-pay, co-insurance or deductible.

    I understand if I fail to come for a scheduled appointment or cancel at least 24 hours prior to the appointment, will be considered a "no show" and may be subject to a "no show" charge per occurrence.

    I understand the Financial and No Show Policies, and hereby agree to them:

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