Dr. Paul B. Roache and his office team are committed to providing you with the highest level of Orthopaedic medical care available.

Patient Financial Responsibilities
By law and courtesy, we must inform our patients of our fianacial policies

Payment in full

Full payment is customary and required at the time of your visit. You, as the patient, are fianacially responsible for the services provided.

Insurance coverage

You can meet your fiancial responsibility by being an eligible member of an insurance company with whom we are contracted. You must provide us with a valid insurance card prior to being seen by the doctor.

HMO Patients

In addition to your insurance card, you must have a valid referral from your primary care MD.

Deductibles

In addition to your insurance card, you must call your insurance comapny and provide us with the documentation that you have met your deductible for the year.

Worker's Compensation

In addition to your insurance card, you will need the following:

1. Your claim number
2. Your employer information and group number
3. comp carrier name and address
4. the name and contact information of your claims representative

If you do not currently have insurance or are a member of a health plan which are not contracted, payment in full is required at the time of your visit.

Co-payment

If you insurance company requires a co-payment, it is due at the time of service. This is a contractual and legal requirement for many health plan contracts.

Assignment of Benefits

Your signature below constitutes full assignment of benefits to our office if we bill your insurance paln, including Medicare. However, if your insurance company does not pay the claim, the bill will become your responsibility.

Payment Arrangements

Payments may be made in cash, by check or credit card (Visa and Mastercard).

Cancellation Charges

Appointments cancelled without a minimum of 24-hours notification may be charged the full appointment fee.

Service Charges/ Late Fees

Any balance carried to the next billing cycle will be subject to a service charge at the following rates:

Account Balance		Fee per month
<$10.00		$1.00
$11.00 - $100		$10.00
$100.00 and over		$25.00

Collections

If it becomes necessary to assign your account to a collection agency and/ or an attorney, you will be responsible for all of our collection agency and attorney fees and costs.

We are happy to discuss with you any questions relating to the preceding information and thank you for choosing our office for your Orthopaedic needs.

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