For services covered by medical insurance, we would be happy to assist you in filing your insurance forms. Please COMPLETE ALL NECESSARY INFORMATION, SIGN ALL AUTHORIZATIONS on the form and designate to whom the form should be sent. Disability forms and Family Medical Leave (FMLA) forms are handled in the same manner. However, any disability or FMLA forms completed by our office are subject to a $10.00 fee, which must be paid in advance.
All co-pays are payable at time of visit. These payments are part of your insurance contract and must be paid to OIO at the time of service. Failure to pay your co-pays at the time of service is a breach of contract between you and your health insurance company and we are obligated to report this lack of payment to your health insurance company. Medicaid patients MUST bring their medical card to each appointment. If you do not have your card and time permits, you may go home and get it; otherwise, we will need to reschedule your appointment.
Please remember that your medical insurance is a contract between you and your insurance company and that professional services are rendered and charged to the patient and not the insurance carrier. Although our office would be happy to help you file your insurance, we cannot accept responsibility for collecting your claim or for negotiating a settlement on a disputed claim. If you feel that your insurance company does not reimburse you, or pay your claims quickly enough, we suggest you give them a call or contact your insurance representative. You pay the insurance premiums and deserve the best service from them. If we receive an insurance payment for any account that you have paid, a refund check will be forwarded to you.
It is the objective of this office to provide our patients with the best care and facilities at a reasonable cost. In an effort to eliminate the expense of billing and collection, we ask that you pay for these services as they are rendered. Upon request, special considerations may be extended in the event of prolonged illness, unemployment, or other circumstances. To avoid misunderstandings, we invite you to discuss financial problems early. A statement of your account will be sent to you on a monthly basis. However, after 120 days, if your account remains unpaid, we will be forced to turn your account over to a credit bureau or attorney for collection. We strongly request that you do not let your account become delinquent.
All office visits are payable in full at the time of your visit. For services rendered outside the office, such as Emergency Room or Cast Clinic, we realize that payment cannot be made at that time. Therefore on your following visit to our office, payment is due on your recent outpatient treatment as well as your office visit.
For surgical and inpatient hospital services provided by our physicians, we will be happy to file your insurance or provide you with the necessary information for you to file your claim. If we do not receive an insurance payment within a reasonable period of time, you will be expected to begin payments on your account. Services rendered may be paid by cash, check, Visa or MasterCard.
A patient must call our office at least three days before their prescription runs out for any medication to be refilled in a timely manner. We encourage patients to call the office during regular office hours for medication refills. Also, note that it is a strict policy of the office that narcotics and other pain medications are not filled after hours or on the weekend by the on-call physician. Please note: OIO charges $8.00 for a phoned-in prescription (new or refill) and $12.00 for multiple prescriptions.
Our office will provide an off-of-work slip or a back-to-work slip, whichever is appropriate, to the patient. It is the responsibility of the patient to provide this information to their place of employment.
If you cannot keep a scheduled appointment, please call our office as soon as possible to cancel and reschedule.
Orthopaedic offices are known to have numerous unexpected emergencies. Your patience and consideration for our emergency patients will be appreciated.
Patients that cannot keep their appointment must give 24 hour notification of the cancellation. Patients that do not notify the office are considered a “no-show” and are subject to a $25.00 charge.
The Orthopaedic Institute of Ohio will always have a physician available to handle any emergencies. If you have a problem when the office is closed, please call 419-222-6622 and select option #4. Should an emergency occur, you will be attended by the physician on call or go to the emergency room. Thank you for your cooperation and understanding, which allow us to provide you with continuing quality medical care.
All forms are in Adobe PDF format and require Adobe Reader to be installed on your computer in order to be able to open them. If you do not have Adobe Reader, please use the link below.
Statements With Dates Prior to 4/10
Statements With Dates 4/11 or After