The medical and therapy services you seek imply a financial responsibility on your part, or on your nominated Parent/Guardian. This responsibility obligates you to ensure payment in full for the services you receive. If someone else (parent, spouse, domestic partner, etc.) is financially responsible for incurred expenses, please share this policy with them, as it explains our practices regarding patient billing.
By signing below and/or by receiving allied health services from Napa Centre you agree:
1. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services.
2. Third Party Payments or NDIS Payments: If a Third Party is authorised to complete payment for incurred expenses on your behalf (eg. NDIA, Plan Manager, Charity, Trust) you agree to provide NAPA Centre with all contact information and give NAPA Centre permission to contact them for the purposes of payment. If they are unable to provide financial security or have insufficient funding to pay for your outstanding debt, financial responsibility returns to the nominated Parent/Guardian.
3. Overdue Payments: All payments for services must be completed in line with the payment policy outlined on the following pages. Payment of any overdue account balances is due within fourteen (14) days of receipt of your tax invoice. If any balance on your account is over fourteen (14) days past due, your account will be in default and auto referred to a collection agency. The balance of any account not paid within fourteen (14) days will begin to accrue interest at the rate of 1.5% per month or the maximum allowed by applicable law, whichever is lower. NAPA reserves the right to cease the provision of ongoing services if overdue payments are not received or outstanding balances are in excess of $600.
4. Additional Charges: Patients may incur and are responsible for the payment of additional charges at the discretion of NAPA Centre including but not limited to: (i) charges for a missed appointments as per cancellation policy; (ii) charges for phone consultations; (iii) charges for copying and distribution of patient medical records; (iv) charges for extensive forms or resource preparation or completion; (v) any costs associated with collection of patient balances, all as allowed by law; (vii) refund processing fees; (viii) cancellation or therapy transfer charges.
5. Non-payment of Account. Should collection proceedings or other legal action become necessary to collect an overdue account, you understand that NAPA Centre has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) all court costs and fees (but only to the extent allowed by law); and (iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third party collection agency. You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account and is not deemed interest as part of a credit transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to comply with any of these policies may also result in a withdrawal of care.
6. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Napa Centre.
7. Authorisation to Contact. You authorise NAPA Centre personnel to communicate by mail and/or e-mail according to the information provided in your patient registration information. NAPA Centre, or any agent orservicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, phone numbers, to contact you for purposes related to your account, including debt collection. You authorise NAPA Centre to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages.
8. Financial Responsibility Party. By signing as Financial Responsibility statement, you hereby guarantee the full and prompt payment to NAPA Centre of all indebtedness of Patient to NAPA Centre, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by NAPA Centre in collecting the Indebtedness, in enforcing this guarantee, or in protecting its rights under this guarantee or under any other document evidencing or securing any of the Indebtedness. This guarantee shall be a continuing, absolute and unconditional guarantee, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of NAPA Centre at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of Financial Responsibility Party.
Acknowledgement
By signing below, you acknowledge that: (i) I have been provided a copy of the Napa Centre FINANCIAL RESPONSIBILITY STATEMENT; (ii) I have read, understand, and agree to their provisions and agree to the specified terms; (iii) I agree to pay all charges due (or to become due) to Napa Centre for the Patient’s care and treatment, as required or provided pursuant to my insurance plan and/or the insurance plan of another, as applicable; (iv) benefits, if any, paid by a third-party will be credited on the Patient account; (v) regardless of my insurance status or absence of insurance coverage, I am ultimately responsible for the balance on the account for any services rendered; (vi) if I failed to make any of the payment for which I am responsible in a timely manner, I will be responsible for all costs of collecting the money owed, including court costs, collection agency fees, and attorneys’ fees (to the extent allowed by law); and (vii) failure to pay when due may subject me to late payment charges and can adversely affect my credit report.