I, the patient acknowledge that I will be held completely responsible for all accrued charges and account balances regarding all services rendered to me at Teton Surgical Specialties, PLLC (Teton Hand Surgery) by Dr. Bruce J Watkins and his office. I understand that any services that are provided MUST BE PAID IN FULL AT THE END OF THE VISIT. I have two options for payments: “Cash” or Credit Card (Visa or Master Card) under the “CASH” Policy Agreement.
The following schedule MUST BE PAID IN FULL AT THE END OF THE VISIT:
- Office Visits – physician consultation fees, follow up appointments, durable medical equipment, such as splints, etc.
- Durable medical equipment, etc. – includes any replacement or additional splints, etc.., required for specified treatment by Dr. Bruce J Watkins, and /or when requested by the patient.
- In-Office procedures – This service is NOT included in routine medical visits fees and is considered a minor “in-office” procedure and will be billed accordingly.
- Surgery – The surgery fee is quoted at a discounted price. Dependent on the actual procedure performed at surgery, the surgery fee may require future adjustments. Fee increases will be billed to the patient, and decreases will be refunded once the account has been adjusted.
- Surgery Center – Their will be a separate bill for the surgery center cost that will be billed from the surgery center. They will give you the cost before surgery and payment will be due the day of surgery.
I acknowledge that I have read and understand the above, and therefore, I will be responsible for payment(s) according to the above fee schedule. I further acknowledge that I DO NOT have any private insurance coverage; therefore, I will not attempt to file any claims at a later time to any insurance carrier for coverage of services rendered to me.
