PLEASE READ:
Due to the increase in high deductible plans, it is now the policy of Pediatric Orthopaedic Surgery Associate to require either a Credit/Debit Card or HSA/Flexible Spending Card to be kept on file for ALL patients. Copays, deductibles and co-insurance estimates will be collected at time of service. Your claim(s) will be filed with your designated insurance carrier/provider.
If your claim comes back with any additional patient responsibility balance such as copays/coinsurance/deductibles you will receive a statement. You will have 30 days from the statement date to pay your balance in full. Any remaining balances will then be charged to the card kept on file. All cards will be stored electronically in our Payment Card Industry (PCI) Complaint & Cyber Security Insured system to protect and alleviate any worries you may have of a cyber-attack. The card information on file visible to Pediatric Orthopaedic Surgery Associates is limited to the last 4 digits of your card number and expiration date. Your card on file can only be used to pay account balances incurred at Pediatric Orthopaedic Surgery Associates, through our secured payment terminal powered by Square Terminal. If you pay your bill by the due date, your card will not be charged. If you would like to use the card on file to pay your bill, do nothing and the card will be charged on the date posted on your statement.
It is YOUR responsibility to notify us of any change to your insurance so that we can determine if there is any change in your benefits.
You, the Patient/Parent/Guardian/Co-Signer, by signing this agreement, agree to allow Pediatric Orthopaedic Surgery Associates to utilize your Credit/Debit Card or HSA/Flexible Spending Card to pay all fees and costs due to Pediatric Orthopaedic Surgery Associates at any time if additional money is owed after your primary insurance carrier has been billed or for amounts excluded from your insurance (i.e. Cancellation/No Show fees). You further agree to allow Pediatric Orthopaedic Surgery Associates to scan the Credit/Debit Card or HSA/Flexible Spending Card kept on file in our secured payment terminal powered by Intuit, Inc.
All account numbers and charges made by Pediatric Orthopaedic Surgery Associates are confidential and are protected from disclosure except as provided by law.
Refusal to provide your credit card information to be stored is in violation of our billing agreement and therefore we reserve the right to refuse service to you. Your signature indicates your understanding and compliance with this policy.