Notice Of Non-Discrimination

Eastside Orthopedics & Sports Medicine, LLC

Notice of Nondiscrimination

Eastside Orthopedics & Sports Medicine, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin (including limited English proficiency and primary language), sex, age, or disability, Eastside Orthopedics & Sports Medicine, LLC provides:

Free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other
formats)
Free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages

If you need these services, contact Angela Roberts at 503-659-1769 or angelar@eosdocs.com. If you believe that Eastside Orthopedics & Sports Medicine, LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, sex, age, or disability, you can file a grievance with: Angela Roberts, 6542 SE Lake Rd Suite 201 Milwaukie, OR 97222, 503-659-1769, 503-659-7522, angelar@eosdocs.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Angela Roberts is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. This notice is available on our website at www.eosdocs.com and in prominent physical locations where we interact with the public. It is also available in large print and other alternate formats upon request.

Contracted Health Plans

The physicians at Eastside Orthopedics & Sports Medicine are participating providers with most major health insurance plans and worker compensation plans. If you have any questions whether your physician is contracted, we suggest that you contact your insurance provider.

Our office accepts referrals from all primary care physicians.

Billing and Payment

Patients are ultimately responsible for paying for the care they receive even if they have insurance coverage. For your convenience, Eastside Orthopedics & Sports Medicine accepts cash, personal checks, debit and credit
cards, (Visa and Mastercard only.)

Health Insurance

If you will be using health insurance to settle your account, you will be asked to present your current insurance card at each visit. Eastside Orthopedics and Sports Medicine will collect any applicable co-pays that apply under your insurance for the visit.Eastside Orthopedics & Sports Medicine will gladly file a claim on your behalf with your health insurance company for the treatment you receive. We will file an initial claim based upon the information you provide to us. Under state law, your insurance company has 30 days to process and pay the claim, request more information, or deny the claim and notify us of the decision. You are responsible for services you receive from Eastside Orthopedics & Sports Medicine that your insurance plan does not cover.

Self-pay

A self-pay account is defined as follows: A patient does not have a valid insurance referral on file; Patient does not have health insurance coverage; Patient is covered under a insurance plan Eastside Orthopedics & Sports Medicine does not participate in. If you are self-pay, you will be expected to pay the day’s charges on the day of the service. If you are having surgery you will be expected to make mutually agreeable payment arrangements before receiving the service.

Workers’ Compensation

Eastside Orthopedics & Sports Medicine provide services under workers’ compensation plans. If you need to see a physician for an injury or illness related to your employment, please contact your employer to complete the “801” first report of injury form. Failure to properly report this injury to your employer may result in your claim being denied. Denied claims will be your responsibility. You will need to provide us with the claim number if available, as well as the address to which the bill is to be sent.

Automobile Injuries

If your visit is related to an automobile accident, Eastside Orthopedics & Sports Medicine request that you provide us with information that will assist us in getting your medical claims paid. Please contact your automobile insurance and request the Personal Injury Protection Forms to complete.

Third party liability claims

If your services are due to a third party liability claim, Eastside Orthopedics & Sports Medicine reserves the right to treat the claims as a self-pay account as the liability claim does not guarantee payment.

Un-canceled appointment fee

Eastside Orthopedics & Sports Medicine requests that patients please give at least 24 hours’ notice (one business day) if they will not be able to keep their appointment. Patients who fail to provide appropriate notice may be charged a cancellation fee of up to $50.00.

Returned checks fee

Eastside Orthopedics & Sports Medicine will charge a returned check fee of $35 for any check returned by your bank for non-payment (insufficient funds).

Billing statements

Eastside Orthopedics & Sports Medicine will send you an itemized statement listing the services you are being billed for and the balance due for the service from both you and your insurance company. All balances are due in full within 30 days of the
statement date. If you have any questions or concerns regarding your account or insurance claim, please contact our Business Office. Our representatives will make every effort to assist you, clarify any misunderstandings, and provide you the
information you need to resolve your problem and restore your account to good standing. Eastside Orthopedics & Sports Medicine reserves the right to report delinquent accounts to credit bureaus, take other collection action, or terminate you as
a patient of this practice.

Disability or Insurance Forms:

We are happy to complete disability forms for you, however, due to the growing number of forms that need to be completed, and the time involved, our office has instituted the following policy.

Forms are completed in the order they are received. All patient information must be completed before we can accept the forms.
Please allow five business days for completion.
Forms cannot be completed until your most recent office note has been dictated and transcribed. This may increase the time it takes to complete the form.
There is a $20.00 charge for forms over 2 pages and a $10.00 charge for one page forms which must be paid before the forms will be completed.
If you are covered under Worker’s Compensation, please be aware that you are responsible for the payment of disability forms; worker’s compensation does not cover this cost.
When forms are complete you will be notified and a copy may be faxed to the insurance company or employer if the patient requests.
NO FORMS MAY BE GIVEN TO THE PHYSICIAN AT ANY TIME.

Surgery Pre-pays:

Eastside Orthopedics & Sports Medicine will contact your insurance for deductible and co insurance percentages. You may be asked to pay a pre-payment prior to your surgery date. Our Business Office will contact you for payment
arrangements prior to the surgical event. The estimate will be only for the surgeon fee. The hospital, surgery center, anesthesia and pathology charges are all separate and will be billed to you by each provider of service.

If you have any questions or do not understand any aspects of this Policy, please contact Eastside Orthopedics & Sports Medicine’s Business Office.

I understand that I am responsible for obtaining any referral which may be required by my insurance.
I authorize Paul D. Ruesch, MD and /or Bret T Kean, MD to release information to my primary care physician.
I authorize Paul D. Ruesch, MD and/or Bret T. Kean, MD to release information to my employer if this is a work related condition.
I hereby acknowledge and understand that if I am scheduled for a surgical procedure that my procedure may be performed at a center that is partly owned by one of the physicians named above.
I authorize photography of my surgical site and understand they will become a part of my medical record.
I understand that I am financially responsible for any charges incurred by myself or dependent whether or not paid by my insurance.
I furthermore assign to Paul D Ruesch, MD PC and /or Bret T Kean, MD PC all insurance payments relative to the services performed.
By signing below, I agree that I have reviewed and understand the information above and I agree to abide by all said terms.

Print Friendly version (PDF) with signature line

Call 503-659-1769 or request an appointment online

Request Appointment

Notice Of Non-Discrimination