FORMS & POLICIES
As with any successful medical practice, we have policies and procedures in place to ensure best practices, fairness to patients and staff, promote quality and responsibility and, ultimately, provide the best possible patient care. Please take the time to read these and contact our office at (309) 692-0123 or info@theknightcenter.com if you have any questions or comments.
POLICIES
-
✦Patient Rights
-
✦Patient Responsibilities
-
✦Prescriptions and Refills
-
✦Labs
-
✦Medical Records
-
✦Payment for Services
-
✦Workmen’s Compensation & Personal Injury
-
✦Letters & Correspondence
Payment For Services
Not all services are covered in all insurance contracts. As a result, some procedures we feel are medically necessary for optimal treatment or preventative care may not be covered by some plans. Due to the differences in various insurance plans and programs, we cannot guarantee that services provided by our practice will be covered under your insurance policy. In addition, our practice may not have a preferred provider agreement with your insurance company. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. It is your sole responsibility to know and determine what medical procedures your policy includes and excludes including specialists, hospitals, lab tests, x-ray facilities and other medical facilities that are accepted and covered by your insurance plan. To find out what your insurance plan covers and what your financial obligation may be, call the member services department listed on your insurance card. Your employer’s human resources department may also be a source of information and assistance. For the convenience of our patients we accept cash, Visa, Master Card, Discover, traveler’s checks, Money Orders and personal checks. Co-payments, co-insurance and deductibles required by individual insurance plans are due at the time services are rendered. We also welcome self-paying patients when insurance coverage is not available for our services. Patients without insurance are expected to assume full financial responsibility for all medical services provided. If, for any reason, full payment cannot be made at the time of service, please contact our office to determine if a reasonable payment arrangement can be established. We accept Medicare assignment of covered charges. Patients will be billed for co-insurance, annual deductibles or any uncovered charges unless the
patient has supplemental insurance.
Workman’s Compensation & PERSONAL INJURY
Workman’s Compensation cases require prior authorization from either the employer or insurance carrier agent before treatment. Should the employer or carrier subsequently deny validated worker’s compensation service, such charges will become the financial responsibility for the patient and subject to the terms and conditions outlined in the preceding paragraphs. In cases of personal injury, we do not defer payment until settlement or judgment. Any patient treated in relation to a personal injury case will be expected to assume full financial responsibility under the terms and conditions outlined in the preceding paragraphs. Claims will be submitted to your insurance company and you will be charged the usual co-payments, co-insurance and deductibles It will be your responsibility to seek personal reimbursement from the sources you feel are responsible. In the case where your health insurance company denies such claims you will be responsible.
FORMS
Click on the form title to open a printable PDF document
Letters & Correspondence
There are occasions when a patient requires a letter or from their physician to justify time off from work or school. We are happy to comply with these requests if they are for a legitimate medical reason in which we had examined or were otherwise involved in the care pertaining to that illness or condition. Under no circumstances will these requests be honored if the patient has not been seen in our office to confirm the complaint.
In situations such as disability or Family Medical Leave Act applications where a physical exam is require, an office visit is required. At that time, the patient and doctor will complete the standard government forms together. Under no circumstances will the patient be allowed to leave these forms to be filled out and picked up at a later date. In these circumstances we use the standard government forms. Although some companies or third parties request we use custom forms, the information required is contained in government documents and it will be the responsibility of the the person requesting these documents to transpose the information.
If a patient requires letters for insurance pre-authorizations or appeals, we reserve the right to charge a fee relative to the complexity of the condition in question as well as the time required to research and complete the letter.
Typical turnaround time for any correspondence is two weeks but may be longer depending on the availability of staff. We appreciate as much advanced notice as possible, especially if there are deadlines involved. Expedited requests may result in a premium service charge.
