Sextro–Larsen Podiatry, PC



Foot & Ankle Clinic

of Central Nebraska

Kevin J. Larsen, DPM Jonathan B. Wilson, DPM Amanda L. Walsh, DPM

Patient Financial Policy

Your understanding of our financial policy is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or Office Manager.

As our patient, you are responsible for all referrals needed to seek treatment in this office. Our office will do all pre-certification for surgical procedures and certain other procedures.

Unless other arrangements have been made, payment for office services are due at the time of service. We accept Visa, Mastercard, American Express, Discover, and Debit Cards, cash or check. If you have insurance, we will bill those plans and you will be responsible for the co-pay, co-insurance or deductible at the time of service.

Your insurance is a contract between you and your insurance company. We will file your insurance claim for you when you assign the benefits to the Doctor. In other words, you agree to have your insurance company pay the Doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.

All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “Not Covered”, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services however you remain responsible for charges to any service rendered. Patients are encouraged to contact their health care plan for clarification of benefits if they have questions regarding services.

For any services provided in the hospital or surgical center, we will pre-authorize your surgery and we will bill your healthcare plan. Any balance due is your responsibility.

There are certain elective procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due prior to the procedure.

Past due accounts are subject to interest charges and collection procedures. Any account 90 days old will be charged at “periodic rate” of 1.2 % per month (annual rate of 14%). Any account not collectible by our office will be filed with a collection service for collection procedures.

There is a service fee of $20.00 for all returned checks.

Signature of Patient ________________________________________ Date __________

Name of Patient/Responsible Party __________________________________________

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