We would like to thank you for choosing Midwest Orthopaedics at Rush, LLC (MOR) as your medical provider. To keep you informed of our current office and financial policies we ask that you read and sign our financial acknowledgement prior to any treatment. Please keep this document for future reference.

Credit Card Policy: MOR requires a valid credit card or direct bank debit account information prior to services being rendered. Your credit card / bank account will not be charged until 60 days after the services provided have been processed by your health insurance carrier and the balance deemed your responsibility. You will be notified by letter and/or phone of any outstanding balances prior to MOR charging your card or account at which time we will inform you of all your payment options.

Canceled Appointments: If you are unable to keep your scheduled appointment, please call our office within 24 hours to reschedule your appointment. This will enable us time to use your slot for another patient.

No Insurance: Payment will be due at the time of service. If you are unable to pay your balance in full, you will need to make prior arrangements with our Customer Service Representative or Financial Coordinator.

Insurance: Please bring your insurance card with you at the time of your appointment. For insurance plans that we contract with, your carrier requires that all co-pays be paid prior to any services being rendered. The co-pay requirement cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier. If you do not have your co-pay at the time of your visit, you must provide us a written waiver from your insurance carrier specifically authorizing MOR to waive this obligation.

You are responsible for any co-insurance, deductibles or non-covered services as required by your insurance. You will receive a statement from our office indicating what your insurance has paid. Any remaining balance is due upon receipt of that statement

HMO or POS: For POS and HMO insurance plans that we participate in, your insurance carrier requires that you obtain a referral from your Primary Care Physician (PCP) before receiving services. Please bring that referral with you. Any services received without a referral or proper authorization will be your responsibility.

Auto Accident Injury: If your injury is due to an automobile accident, we request that you provide us with any information that will assist us in getting your medical claims paid. This information may include:

• a copy of the police report
• a copy of your auto insurance
• medical insurance
• names and information on other parties involved

Liability Injury: If your injury is a result from another party's negligence, we request that you provide us with any information that will assist us in obtaining reimbursement for the services rendered to you. This information may include:

• a copy of the accident report listing claim number and responsible part
• medical coverage and/or attorney information

Worker's Compensation: If your injury is due to an accident in your work place, please be sure to contact your employer and inform them of your injury. We will need to receive authorization from your employer before we can process any of your medical claims. Please have your employer contact our Worker's Compensation Department at 877-632-6637. Failure to properly report this injury to your employer may result in your claims being denied. Denied claims will be your responsibility.

Return Checks: A $30.00 charge will be added to your account for any check returned by your bank for any reason.

Disability or Insurance Forms: There will be a charge of $15.00 - $35.00 for the completion of medical forms (charge is based upon number of pages and complexity of information requested). Payment is due at the time that you pick-up the forms. Please allow 7 - 10 days for the completion of these forms. If you would like the forms mailed to you or your insurance company, payment will be due prior to mailing.

Medical Records: We will provide you a copy of your medical records upon request. You will need to sign a letter of release at the time of pick-up. Please allow 7-10 days for us to copy your records. If you wish for your records to be mailed, there may be an associated fee to cover the mailing costs. You may be charged for additional copies of your medical record. Rates charged are within Illinois state statutes.

X-Rays: We will provide you with a copy of your x-rays upon request. You will need to sign a letter of release at the time of pick-up. Please allow 48 hours from the time of your request. There is a $3.50 charge per x-ray, that is payable at the time of pick-up. If you have any questions or concerns, please contact our Customer Service Department at 877-632-6637.

If you have any questions or concerns, please contact our Customer Service Department at 877-632-6637 (877MD Bones).

Thank you for allowing us to service you.

Revised 3/30/07

Financial Policy PDF
MOR Credit Card Consent