Notice and Acknowledgement of Financial Obligation

In order for Midwest Orthopaedics at Rush, LLC to schedule your surgical procedure, information or a deposit is required to hold your surgical appointment slot. Our policy requires you to provide a valid credit card, bank account information or a $500 deposit.

With the rising costs of healthcare and consumer driven plans, our contracts with your health insurance carriers encourage upfront collection efforts in order to help facilitate the settlement of any balances that you may be responsible for after your health insurance carrier has processed your claim.

This financial obligation form acknowledges your decision to decline our policy and holds you directly and fully responsible for all services rendered by Midwest Orthopaedics at Rush, LLC.

In signing this form, you understand that you are responsible for prompt payment of any portion of the charges applied to your deductible, co-pay, co-insurance carrier. In the event you default, you will be charged interest on your total balance due at an annual rate of 10% and you will also be responsible for paying all reasonable attorney fees and collection costs.

Midwest Orthopaedics at Rush, LLC also reserves the right to seek payment as provided by the Health Care Services Lien Act (770 ILCS 21/1 et seq.) against any responsible third party.

Your signature below acknowledges that you fully understand this policy and agree to its terms.

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Notice and Acknowledgement of Financial Obligation