I consent to the disclosure of my protected health information by Arrowhead Orthopaedics for the specific purpose of diagnosing or providing treatment, and obtaining payment for my health care bills.
I have read The Notice of Privacy Practices (click here to view),which describes the use and disclosure of my protected health information that will occur during my treatment and bill payment. This Notice of Privacy Practices also describes my rights and the duties of Arrowhead Orthopaedics with respect to my protected health information. I may obtain a copy of the Notice of Privacy Practices at anytime by accessing our website, calling the office and requesting a copy by mail, or asking for one at the time of my next appointment.
Payment Responsibility: As the individual seeking care, I am responsible for payment of all charges associated with my visit. As a courtesy, and for my convenience, AO will bill my insurance company when I have provided the requested insurance information. I am responsible for annual deductibles, co-payments, percentages, and uncovered services at the time the service is rendered. If uncertain of my coverage, I will contact my insurance carrier. If the insurance payment is not received within 60 days of AO’s office billing, I am immediately responsible for the full account balance. It is the policy of Arrowhead Orthopaedics that in the case of separation or divorce, the parent bringing in a child for treatment is responsible to pay for services.
Patient Billing: Patients who have outstanding balances are billed monthly. All balances are due within 30 days from the billing date. When the account balance has not been paid within 30 days and I have not contacted the office regarding the account, my account may be referred to an independent collection agency along with necessary information to assist with collection. Once an account has been referred to collections, Arrowhead Orthopaedics will suspend services until payment is made in full or acceptable payment arrangements have been made. All costs incurred in the collection process shall be added to the original balances due.
Methods of Payment: AO accepts cash, personal checks, Visa, Mastercard, American Express and Discover.
Returned Checks: A $45 fee is charged for all returned checks.
NOTICE OF FINANCIAL INTEREST
In compliance with California law found in business and professional code section 654.2 and labor code 139.3, I understand that my surgeon has an ownership interest in Arrowhead Orthopaedics, Advanced Ambulatory Surgery Center, Arrowhead Orthopaedic Physical Therapy, Inland Surgical Products, LLC, and Renovis Surgical Technologies that supply orthopedic surgical goods and services. I understand that I am free to obtain orthopaedic instrumentation or surgical services of my choosing.