Office / Financial Policy Agreement

Please read carefully!

Office hours are by appointment only.  If this is your first visit, please arrive 1 hour early.  If this is a follow up visit, please arrive 15 minutes early.  If you arrive more than 10 minutes late, you may be asked to reschedule.

For emergencies, call 911 or go to local emergency room. 

For non-emergent issues that CANNOT wait until regular office hours, please call our office.  A message will guide you to the doctor on call.  There will be a charge for this and is not covered by insurance.

Insurance: We participate in most insurance plans.  As a courtesy to our patients, we bill all primary and secondary insurances.  At each visit, you will complete a paper registration form, provide your current insurance card and a photo ID.  You are responsible for all co-pays, co-insurance, deductible and non-covered services not paid by your insurance company.  Knowing your insurance benefits is YOUR responsibility. Your insurance company may need you to supply information directly to them; this is your responsibility. A billing statement will be sent after your insurance company has processed your claim.  Payments are due upon receipt of a billing statement. 

Dispute of Insurance Payment: If you feel your insurance company has processed your claim incorrectly, it is YOUR responsibility to contact the insurance company to resolve the dispute.  Diagnosis will not be modified to fit your insurance benefit.

No Insurance/Out-of-Network Care/Self Pay:  If you do not have insurance, or if we are out of network with your insurance, or you cannot provide an insurance card at the time of service, you will pay in full for services at the time of your visit.  As a courtesy to our out-of-network patients, we will file your insurance claim.  Blue Cross Blue Shield (BCBS) and Preferred One (PONE) are out of network and will not pay 3rd Opinion.  It is unlikely they will cover any services at 3rd Opinion so expect no reimbursement from your insurance. Therefore, BCBS and PONE patients must pay at the time of service.

Payment Options:  We accept cash, in-state personal checks, Discover, MasterCard and Visa.

Service Charge for Returned Checks:  A service charge of $40 will be added to your account for any check returned to us from your bank.

Minor/Dependent of Divorced or Separated Parents:  Both parents are financially responsible for all services rendered to minor/dependent children regardless of who is the statement recipient on the account.

Reminders of Appointment:  As a courtesy, our office will send a reminder via e-mail, text or phone.  Please reply to this reminder. 

If we do not receive a reply to the reminder at least two business days prior to your appointment, we may reallocate the appointment to someone else.

Cancellation of Appointment: To be respectful of the medical needs of our community, please be courteous and call our office promptly if you are unable to attend an appointment. 

If a patient fails to call or show for his/her scheduled appointment twice, he/she will be discharged from 3rd Opinion Co.

Prescription Refills:  New prescriptions will not be issued without first seeing the physician. 

Prescriptions for acute care or chronic conditions are written with an appropriate number of refills to complete the course of treatment or to last until your next scheduled appointment. 

Therefore, refills should be accomplished at regularly scheduled appointments. Prescription refills (not requested during the office visit) may be charged $20 each.

Controlled medications are not refilled over the telephone at any time.  Narcotic pain medications and stimulant medications/ADHD treatment medications will not be prescribed by Dr. Thomas Sult. 

Insurance Covered Medications: If a prescribed medication is not covered by insurance, it is YOUR responsibility to contact your insurance company to ask what “alternative medications” are covered. 

E-mails requiring a reply by Dr. Sult are charged $30 each.  If Dr. Sult feels the e-mail is more complex than can be addressed via e-mail, he will ask you to follow-up.

Letters/Form Completion.  Letters and forms requiring medical review and physician signature require an appointment with Dr. Sult.

Disability Paperwork Requests.  Dr. Sult will complete disability paperwork requests only after he has seen the patient at least 4 times and he feels completely familiar with the patient’s entire medical condition before offering his opinion on disability.

Requests for Medical Records.  We require written requests including the patient or legal guardian’s signature for the release of medical records.

Referrals.  If your managed care plan requires approval or authorization for referrals to a specialist, radiological imaging, etc., it is your responsibility to inform our office of this requirement prior to referral.  We require 3 business days’ notice to facilitate a referral request and cannot issue retroactive referrals.

Privacy, Vital Signs and Laboratory Policies

Patient Privacy Policy:  Our Patient Bill of Rights are posted in our reception area.  Please notify staff if you would like a copy.

Vital Signs Policy:  Vital signs are an important part of your medical care. Vital signs alert us to early trends and changes that may be the first sign of the need to change your therapy. For that reason, vital signs are REQUIRED at every visit at 3rd Opinion. Additionally, vital signs are a required component for your insurance company to cover your office visit.

Laboratory Policy:  Patients will be asked to follow up in the office to review their laboratory results.

It is the interpretation, understanding and interventions based on these lab results that is the complex part. At 3rd Opinion, we require patients to follow up with Dr. Sult for the review of labs so that all of the therapeutic options can be reviewed, informed consent provided and therapy started (if applicable).  Whether your labs are better, worse or the same, therapeutic decisions about keeping or changing your treatment are required.

Often people ask for their results and we are happy to send them, but we will not respond to questions about labs over the telephone or via e-mail. For all of the above reasons, an in office, face-to-face visit is required to place the labs in the larger context of your medical care.

Please note labs drawn while at 3rd Opinion are sent to various laboratories.  These laboratories will bill your insurance and 3rd Opinion does not have control over billing of these services.  Please call the phone number for your insurance company (which is on the back of your insurance card) to verify coverage of lab work and blood draw.

Thank you for choosing 3rd Opinion Co. for your specialty medical care.

I agree I have read and understand all of the terms.

 By signing this Office/Financial Policy, I agree that I have read and understand the terms of this policy. 

Signature Date

Printed Name

Financial Policy