Forms & Info

If you have not pre-registered, please arrive 25 minutes before your scheduled appointment to complete all necessary forms. If you have completed a full pre-registration, please arrive 15 minutes before your scheduled appointment time. This helps us to keep appointments on time and total wait times down.

Please allow a minimum of two hours for your visit. The first 30 to 45 minutes of your appointment will be spent checking-in, filling out paperwork, and having X-rays taken.

We are a high-volume practice. Dr. Clark and his staff practice shared decision-making and are dedicated to spending sufficient time with each patient to listen, diagnose your condition, discuss recommended treatment options, and address any questions or concerns that you may have. Please be aware that this may result in longer wait times.

You may be asked to change into a gown for your exam. For your convenience and comfort, you may instead follow these recommendations:

• Knee exams
  • Wear loose-fitting, non-denim pants or shorts
• Hip exams
  • Wear shorts, sweatpants, or athletic pants
• Back and Shoulder exams
  • Wear a sports bra

Please note that, despite following these recommendations, some situations may require that you change into a gown for your examination.

During your examination, Dr. Clark, Brenda Cooper, and staff will talk to you about your injury/condition. You can aid in your diagnosis and treatment by being prepared to answer these common questions:

• What is your reason for being seen?
• What do you expect from today’s appointment?
• What are your symptoms?
• When did these symptoms start? Was there an injury? What were you doing when these symptoms started?
• What activities make your symptoms worse/better?
• Have you ever had this problem before?
• Have you been treated for this problem before? Who did you see? Were any tests performed (i.e. labs, X-rays, MRIs, etc.)? What was the diagnosis? Did you receive any treatment at that time?
• Have you ever had surgery in that area?
• What home treatments have you tried (including over-the-counter medications)? Did they help?

ACCEPTED INSURANCE PLANS

We regularly review and update our accepted insurance plans. Please contact your insurance carrier directly before your appointment to verify your coverage. You will be responsible for any expenses not covered by your insurance plan.

INSURANCE CLAIMS

We will submit all claims and necessary supporting documentation with participating insurance carriers on behalf of our patients. Any studies or treatments will be pre-certified with the insurance provider prior to dispensation.

DEDUCTIBLES AND CO-PAYMENTS

Many insurance plans include provisions for deductibles and co-payments. The amount of each will be determined by your specific plan. Any co-payment required by your plan will be collected at the time of your visit. It is the patient’s responsibility to understand his or her specific insurance policy.

NON-COVERED TREATMENTS

Our clinic offers some treatments that are not covered by insurance plans. Should we recommend these treatments to you, you will be notified of all out-of-pocket expenses prior to beginning treatment and asked to sign a “non-covered service waiver.” Payment for these services will be required in full before beginning treatment. Common non-covered treatments that we offer include platelet-rich plasma (PRP) injections and certain durable medical goods (such as braces).

REFERRALS

If your insurance carrier requires referral prior to your visit or treatment, it is your responsibility to provide us with the name of your referring physician. If you do not have a referral prior to your visit, you may be responsible for the full payment for your office visit or procedure, or you may need to reschedule your appointment.

SELF-PAY POLICY

We consider patients who do not have insurance to be “self-pay” patients. As such, you will be required to pay a $300 deposit at the time of your visit. Payment must be made in cash, by credit card, or money order. Future visits, surgery, and treatment will require further pre-payment. Until payment is made, you will not be seen.

OUT-OF-POCKET EXPENSES

Out-of-pocket expenses are dependent on the level of your insurance coverage. After we have received final payment from your insurance carrier, you will be billed for any remaining patient responsibility balance, as indicated by your insurance carrier. You are responsible for any deductibles that have not been met.

OUT-OF-NETWORK PATIENTS

If your insurance carrier does not have a contract with Cedar Valley Medical Specialists, P.C., you are considered an out-of-network patient. We will submit your claim to your insurance carrier, however, as an out-of-network patient, your out-of-pocket expenses may be higher than you would experience with an in-network provider.

Please note: out-of-network patients may receive the claim check directly via mail. Should you receive such a claim check, you are responsible for signing and forwarding the check to our billing office.

HOSPITAL BILLS AND PHYSICIAN FEES

Hospital services provided by your primary care physician or other specialists such as anesthesiologists or consultants will be billed separately to either your insurance carrier or you. Please direct any questions regarding these bills to the hospital or surgery center where you underwent the procedure. Our office has no control over these charges.

Charges for your hospital stay are based on the length of your stay and the services and treatments that you received over that time. These specific charges will be itemized on your bill from the hospital. Please direct any questions regarding this bill directly to the hospital.

LATE ARRIVAL

Please arrive on time to your scheduled appointment. We strongly recommend that patients arrive 25 minutes early to fill out any paperwork that may be required. Patients who arrive more than 30 minutes past their scheduled appointment may be asked to reschedule, and may be charged a late-cancellation fee.

CANCELLATION

If you plan to cancel, please notify us no less than 24 hours before your scheduled appointment. You may be charged a $25 late-cancellation fee for cancellation less than 24 hours in advance or missed appointments. Repeated failure to make scheduled appointments may result in release from the practice.

MINORS

Minors must be accompanied by a parent/guardian.

Older minors may be seen upon completion of the preauthorization form. Please complete the form and fax it to our office, or send it with your teen to their appointment.

Unaccompanied minors without parental preauthorization will be rescheduled.

PRESCRIPTION REFILL POLICIES

We will only prescribe medications to current patients who have been seen within the past three months. If you require a long-term anti-inflammatory or other medication, we recommend that you contact your primary care physician.

We cannot call in narcotic pain medications. Refills of narcotic pain medications must be picked up at our office by you or a person appointed by you. No prescriptions will be dispensed without a photo ID.

No prescriptions will be dispensed:

• After 4:00 p.m. Monday-Thursday
• After 12:00 p.m. on Friday
• On weekends

Call our office for any refill requests. Please allow at least 48 hours for your prescription to be renewed.

SELF-PAY

We consider patients who do not have insurance to be “self-pay” patients. As such, you will be required to pay a $300 deposit at the time of your visit. Payment must be made in cash, by credit card, or money order. Future visits, surgery, and treatment will require further pre-payment. Until payment is made, you will not be seen.

DURABLE MEDICAL EQUIPMENT

Prior to receiving durable medical equipment, including, but not limited to, braces, splints, immobilizers, slings, and walking boots, patients must sign an “Advance Beneficiary Notice” (ABN). This ABN will clearly indicate the durable medical equipment that you may elect to receive, the reason that you are receiving the equipment, and the estimated cost of the equipment. By signing this form you consent to pay for the balance due on durable medical equipment dispensed should your insurance provider fail, in whole or in part, to cover the cost of the equipment. We will not offer refunds, nor will we accept returns or exchanges, for durable medical equipment once you have left our office. It is your responsibility to ensure the proper fit and function of any and all dispensed durable medical equipment prior to leaving our office.

DISABILITY, FMLA, AND CLAIM FORMS

The wait time for completion of forms is approximately 10 business days. There will be a $10 service fee charged for the completion of these forms.

WORKERS’ COMPENSATION

Workers’ compensation appointments must be scheduled by your case manager or worker’s compensation adjuster. Our practice cannot make an initial appointment directly with a patient. Case managers must provide us with complete workers’ compensation information in writing prior to scheduling an appointment.

It is your responsibility to provide our office with complete insurance information, as well as contact information for your case manager. Our office will only submit open claims on your behalf, unless we are made aware in advance that the claim will be denied.

Should your workers’ compensation claim be denied, we will bill your primary insurance carrier for the full amount of your visit and treatment. Any balance not covered by the workers’ compensation claim and primary insurance carrier will be the responsibility of the patient.

MOTOR VEHICLE ACCIDENT (MVA) AND LITIGATION CASES

Our clinic does not recognize MVA and litigation cases. Unless you have active health insurance coverage and we receive a letter of subrogation from your insurance company, you will be classified as a self-pay patient.

Should your health insurance carrier determine that your claim should be refunded due to third-party liability, you will be responsible for handling the bill through a litigation attorney. For no reason should you delay payment due to ongoing litigation. Payment of the bill is the responsibility of the individual who has received the treatment, not the individual who is being sued.

We encourage our patients to access their medical records via the Patient Portal

This will be the quickest and easiest way to access your medical records.

If you prefer, you may instead mail or fax the Medical Records Release form to our office.

Expect a wait of approximately 10 business days for the fulfillment of any medical records requests. Records requests are processed in the order that they are received. There is no charge for written medical reports. X-ray CDs will be provided upon payment of a $10 service fee.