Fogarty Surgical Services & Family Care Clinic
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Same Day Appointments
Available in All Offices. We’re here when you need us!
Office Hours

Monday - Friday
8:00am – 4:30pm
10:00am – 3:00pm
Walk-Ins Welcome

Monday and Wednesdays
9:00am – 3:00pm

Rice Lake:
Monday - Friday
8:00am – 4:30pm

Mon, Wed and Friday
9:00am – 3:00pm
or by appointment


Insurance & Forms
Payment for Services | Health Insurance | Self Pay
Auto Insurance/Legal Claims | Worker's Compensation | Insurance Plans
Billing Statements | Past Due Accounts | Billing Questions

Forms to Complete
Please print out and complete the forms below and bring them with you to your appointment.   Registration Form | Health History | Privacy Practices Financial Policy

Payment for Services
Payment for services provided to you is ultimately your responsibility. For your convenience, we accept cash, personal checks, Visa and MasterCard. In addition, if you have health insurance, we will gladly file a claim with your health insurance company. Click here for Financial Policy...

Health Insurance
If you will be using health insurance to settle your account, you must present your current insurance card at each visit. This is a requirement of your insurance company. It also enables us to have the most current information about billing your insurance company. Your insurance company also requires us to collect any applicable co-payments at the time of service. Fogarty Surgical Services & Family Care Clinic has agreements with several insurance companies, which require us to bill them for services provided to you and accept as payment the amount specified in the agreement. You will be responsible for all amounts not paid by them, including amounts denied, applied to deductible, or considered non-covered as permitted by your insurance company.

We will file an initial claim based upon the information that you have provided to us. Under state law, your insurance company has 30 days in which to process and pay the claim, request more information, or deny the claim and notify us of the decision. If they have not notified us within 90 days of the date of service, it will be assumed that your insurance coverage is no longer in force and the unpaid balance will be your responsibility.

Self Pay
If you are self-pay, you will be expected to pay the day's charges on the day of the service. There may be additional charges for tests and other services rendered subsequent to your visit. You will be billed for these items. If you are having a surgery, you will be expected to make mutually agreeable payment arrangements prior to receiving the service. If the service is considered elective, payment must be made in full prior to the services being performed. Click here for printable Self Pay Form...

Auto Insurance/Legal Claims
If you are seeing a physician as a result of an auto accident or other injury related to a legal claim against a third party, you will be considered self-pay. We will file a claim with your auto insurance company for payment, but if balances are not paid within 90 days you will be considered self pay and responsible for payment of balance. Fogarty Surgical Services will not wait for court settlements to be resolved.

Worker's Compensation
Several of our physicians provide services under workers compensation plans. If you need to see a physician for an injury related to your employment, please have your employer or workers compensation case manager make the appointment. You will need to provide us with the case number as well as the address to which the bill is to be sent. Click here for printable Worker's Compensation Form...

Billing Statements
We have designed our billing statements to reflect the individual charges billed, the payments and adjustments related to those charges, and the balance due. These statements will also reflect an amount due from you as well as a balance due from your insurance company. Patients with a personal balance will receive a monthly statement showing the specific amounts due. These statements are due upon receipt. Because the posting of payments can sometimes lag 2-3 days following the day of payment, you may receive a statement that does not reflect a payment that was made on the day of service or sent by your insurance company. If you receive subsequent statements, which do not reflect the payment, please contact us to investigate.

Past Due Accounts
Past-due accounts cost both time and money; therefore, patients with delinquent accounts will be required to make payment at the time of service. If you are unable to make mutually agreeable payment arrangements, we will be glad to reschedule your appointment. Interest will be charged at an annual rate of 18% on all past due patient balances.

Seriously past due accounts - those older than 90 days or those failing to honor agreed-upon payment terms - will be sent to a collection agency. If your account is sent to a collection agency you must pay all past due amounts or make agreeable payment terms before subsequent appointments can be scheduled. Additionally patients can be dismissed from our practice for financial matters and will have to seek their health care elsewhere.

Billing Questions
Questions or concerns regarding your account or insurance claim should be directed to our Business Office. These highly trained experts in insurance billing have been instructed to make every effort to clarify any misunderstanding or confusion you may have regarding your account. Please notify us immediately if you feel an error appears on your statement or if you have any questions or concerns.

Insurance Plans
Fogarty Surgical Services & Family Care Clinic participates with the following insurance plans: (Please call us regarding any other plans not listed here)

Community Employers' Health Alliance
Golden Rule
Group Health
Health EOS
Health Partners
Labor Care
Select Care
Preferred One
Security Health Plan
Select Care
United Healthcare
WEA trust
WI Medicaid & BadgerCare

Fogarty Surgical Services & Family Care Clinic - Hayward Phone 877-934-3123 / Rice Lake Phone 877-434-3124
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