New Patient Form

You should be aware that in the event an out of network insurance plan covers all or part of your treatment, payment for some may be mailed directly to you. If an insurance company sends you payment, they are meant to be sent to PPOS. It is your responsibility to send immediately with all the associated paperwork from the insurance company. As a courtesy to our patients, we file insurance; however, we will not become involved in disputes between you and your insurance companies regarding deductibles, co-payments, covered charges, secondary insurance, or other matters regarding payment.

I hereby authorize Preferred Pediatric Orthopedic Surgery to appeal any denial or fair compensation for coverage by my health care provider for services rendered by Preferred Pediatric Orthopedic Surgery to my child. I further understand and acknowledge that any payment issued by my insurance carrier for services rendered by Preferred Pediatric Orthopedic Surgery as a result of this appeal must be remitted to Preferred Pediatric Orthopedic Surgery. In the instance my appeal is denied, I remain responsible for all payments due and owing Preferred Pediatric Orthopedic Surgery for services rendered.

You, the patient, are entitled to any and all records that pertain to your medical condition. For medical/legal reason we never release the original records. Records are only released to the patient or someone that the patient specifically designates. Copies of the office assessments, outside test results, and x-rays are available. If you would like to view your records or obtain copies of your records the office will comply with your request within 30 days after a written release is received. Please note that there is a fee for copying records and x-rays.

Effective May 1, 2021 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours’ notice will be considered a No Show and charged a $25.00 fee. Any established patient who fails to show or cancels/reschedules an appointment with no 24 hours’ notice a second time will be charged a $50.00 fee. If a third No Show or cancellation/reschedule with no 24-hour notice should occur the patient may be dismissed from PPOS. Any new patient who fails to show for their initial visit will not be rescheduled. The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.