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Clinical and Financial Policies

Thank you for choosing The Orthopedic Specialty Clinic at TOSH. We look forward to providing you with the best possible medical and surgical care. The following information will help you receive care and communicate with our office.

Our office is participating in a US Federal Government program called “Promoting Interoperability” formerly called Meaningful Use or MIPS. The purpose of this program is to improve the delivery of Health Care through the use of electronic medical records which can be shared with patients and other providers.


We have implemented the Intelichart Patient Portal. Your health information is available right at your fingertips 24 /7. At first it may seem new and different, but as you learn to use it, you will find it saves you time and helps us provide better care.

The portal is the fastest way to:

  1. Request a medication refill
  2. Request an appointment or verify the date and time of existing appointments
  3. Ask your physician a question, at any time using secure communication. We respond to questions during our normal working hours.
  4. Decrease in-office wait time by completing forms online at home with access to your records.
  5. Send us documents securely.

If you have not already established a portal user account, please call and request access. We will send you an email with a link to get started.


If you need refills on your medications please make the request through the patient portal. You may also contact your pharmacist who will refill your prescription or contact us if needed. Please let us know during your office visit, if you do not have remaining refills or are running low. If you need a refill on narcotics medications, call our office, between the hours of 8:00 am – 4 pm Monday - Friday. Please allow 48 hours for your requests to be processed. This service is done at no cost. Medication refill requests should be done during regular business hours. After hours phone calls are for urgent/emergent concerns only.


To provide the best possible care, and allow for accurate billing, it is important to have your correct demographic information and accurate information about your health insurance coverage. We will review this information at each visit (even if you have recently been seen), including:

  1. Your legal name, address, and phone number
  2. Insurance information, including: name(s) of the insurance company, the group and subscriber number or other identifying numbers; claims filing address and telephone number
  3. A copy of your insurance card(s) and photo ID, and
  4. The name, address and phone number of the doctor who is referring you to our office

To provide services, we expect payment of your bill as part of the process. We recognize that healthcare benefits and coverage options have become increasingly complex. Please review the financial policies that follow to help you better understand your responsibilities as a patient and our commitment to you. We look forward to working together to ensure accurate billing and prompt payment for the services we provide. If you have any questions regarding the information provided, please ask to speak to a Patient Service Representative.


Your health insurance policy is a contract between you and your health insurance company. It is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals and/or pre-authorizations. You should be knowledgeable about any deductibles, copayments and/or coinsurance that are due.

Our doctors are contracted with most major insurance plans. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details of your benefits, out-of-pocket expenses, and coverage limits.


You are responsible for obtaining and providing us with any if referrals required by your insurance. Without this information, your insurance company may not pay for services, and the balance may be your responsibility. Your appointment may be rescheduled or alternative payment arrangements (see “Self Pay” section) may be necessary without appropriate documentation and approval prior to your visit.


All co-payments are due at the time of service. Your secondary insurance may or may not cover your co-payment and/or co-insurance. If your secondary does not cover your co-payment we will request payment at that time. We accept cash, or credit cards. If you do not make these payments, your appointment may be rescheduled. We are now requesting a credit card to be on file.


As a courtesy we will bill your insurance according to all federal, state and other contractual requirements in cases where we have an agreement, or we are a participating provider. Your insurance will determine what amount they will pay toward your bill. Once they have paid, we will send you a detailed bill for the remaining amount owed.


Not all insurance plans cover all services. If you’re insurance plan determines a service to be “not covered”, you may be responsible for the complete charge. You agree to pay any portion of the charges not covered by insurance. The balance is due in full within 30 days of receipt of the statement. If you are unable to pay the full amount within 30 days, please call 801-314-4145 to make payment arrangements.


We recognize that personal circumstances may make it necessary for you to cancel your appointment. Please contact us as soon as you know you will not be able to keep your appointment.

We understand that on rare occasions, emergencies arise causing you to miss your appointment without the ability to notify our office prior to your appointment. Should this occur, please call our office to have your appointment rescheduled. Patients who miss more than one appointment, without notifying our office, could be subject to a $50.00 missed appointment fee.

A frequent pattern of appointment cancellations and/or visit “no shows” may result in a patient’s discharge from our care, as such cancellation makes it challenging for our doctors to provide appropriate continuity of care and inhibits care we can provide to other patients.


When care requires surgery, our staff will work with you to schedule a date. Surgical resources are complicated involving many people, lab tests and results, special equipment, the limited availability of the surgeons, hospital operating room availability, hospital beds and many additional factors. It takes a lot of time and effort to make these arrangements. Once preparations have been made, it creates additional work for our staff when patients cancel because of last minute personal scheduling inconveniences. Patients will be asked to pay a $250.00 surgery deposit, if a cancelation of surgery for non-medical reasons is made within 2 weeks of the date scheduled, you may lose your deposit. The deposit will be refunded or applied to new surgery date if scheduling changes are due to medical reasons.


I agree to pay all amounts owed within 30 days of when such amounts are incurred. Payment plans can be arranged when necessary. Regardless of insurance coverage, I agree that it is and remains my responsibility to pay all amounts owing. Delinquent accounts will be sent to a collection agency, and the patient may be discharged from the practice for lack of payment. If the account is sent to collections, the person financially responsible for the patient’s account will be responsible for all collection costs, including potential attorney fees and court costs including a collection fee of up to 40% of the principal amount owing as allowed by Utah Code sec 12.1.11.


If you are a workers’ compensation case you need to present a letter, on company letterhead, that includes the following:

  1. Name, address and phone number of Workers Compensation carrier.
  2. Your Case Adjuster’s name, phone number with extension and fax number.
  3. The name of the Nurse Case Manager if one has been assigned.
  4. Permission to treat the patient

If you do not provide this information or your Workers Compensation carrier does not pay your claim, you will be considered self-pay.


Self-pay accounts are for patients without insurance coverage or patients covered by insurance plans with which The Orthopedic Specialty Clinic is not contracted (or when appropriate referrals are not obtained). It is your responsibility to know if our office participates with your plan. Self-pay patients will need to pay for services at the time of the appointment. Please contact office for discounted Self-pay prices.


Completion of disability forms, FMLA forms, and other supplemental insurance forms all require doctor and staff time to complete. There is up to a 14-day turnaround time for completion, so please plan accordingly.

We follow the laws of the State of Utah for copying fees and release of medical records including copies of x-ray images. Most requests for release of records are processed within 2 weeks of receipt, though up to 30 days may be required. A processing fee may be charged for requests sent directly to a patient, or a law firm. Payment is expected prior to release of records.


I assign all medical and surgical benefits to which I am entitled. I hereby authorize and direct my insurance to issue payment directly to The Orthopedic Specialty Clinic at TOSH for medical services for myself and/or my dependents. I have read and understand the financial policy and I agree to be bound by its terms. I understand and agree that such terms may be amended by the practice from time to time. Further I understand that if I do not fulfill my financial obligations, I may be discharged from the practice.


I consent to being contacted by any telephone number, including wireless/cellular phone number provided by me or anyone associated with me or acting on my behalf at The Orthopedic Specialty Clinic or anyone acting on its behalf. I understand and agree that such calls may be initiated by TOSC or any of its affiliates, agents, contractors or assigns, including but not limited to billing companies or third party collection agencies and the methods of contact may include using pre-recorded /artificial voice messages or receiving e-mails at any email address provided by me or anyone associated with me or acting on my behalf.


I consent to health care services provided by the Orthopedic Specialty Clinic (TOSC), its medical staff and employees (including nurses and other health care providers and assistants) Health care services include, medical, surgical, diagnostic, and therapeutic services implementing of physician orders, tests, treatments and procedures ordered and performed in the good faith belief that they are medically necessary and appropriate.

Patient or Patient’s Authorized Representative:


Printed Name:

Relationship to Patient:

Last revision December 4, 2020

5848 South 300 East
Suite 110
Salt Lake City, UT 84107

Tel: | Fax:
Parking Directions

We are located in the South East blue parking lot. Entrance #3 shown in Blue is the closest parking to our clinic