Equestrian Orthopedic Solutions, PLLC

 

Financial Responsibility Agreement

 

Practice Model Notice: Equestrian Orthopedic Solutions, PLLC operates as a direct-pay, concierge orthopedic service. We are a self-pay provider and do not participate with any private insurance companies, Medicare, or Medicaid programs. Patient Financial Responsibility By signing this agreement, you acknowledge and agree to the following:

 

• All services must be paid in full at the time of service.

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• Accepted payment methods: cash, credit cards, debit cards, and checks.

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• We do not bill insurance companies or submit claims on your behalf.

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• You may independently submit documentation for potential out-of-network reimbursement; Equestrian Orthopedic Solutions assumes no responsibility for said reimbursement.

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• You are responsible for all charges, including but not limited to office visits, procedures, injections, X-rays, and telemedicine visits. A current fee schedule is available upon request. Any fees for additional services or procedures will be discussed and agreed prior to performance.

 

Missed Appointment & Cancellation Policy

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• Appointments must be canceled or rescheduled at least 24 hours in advance.

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• Missed or late-cancel appointments may incur a $100 non-reimbursable.

 

Acknowledgment: I have read, understand, and agree to the financial responsibility policies of Equestrian Orthopedic Solutions, PLLC. I accept full financial responsibility for all services rendered to me.

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