Your signature below forms a binding agreement between Paramount Urgent Care (the provider of medical services) and the Patient who is receiving medical services, or the Responsible Party for minor patients (those under 18 years of age The Responsible Party is the individual who is financially responsible for payment of medical bills. HIPAA: If you would like a written copy of the HIPAA laws, please notify our staff. If not, signing below acknowledges that you have waived the written copy. Co-Pays: All co-payments and past due balances are due at the time of services. If your insurance requires any additional co-payments you will be responsible for payment and will be billed for it. As we are an Urgent Care facility, the urgent care co-payment will apply. If no urgent care co-payment is listed on your card; we will charge you the specialist co-payment.
** Sorry we are unable to accept checks for first time patients**
HMO Plans: If my insurance plan is an HMO, I understand that an authorization from my primary care physician may be required for my insurance company to cover services provided by Paramount Urgent Care. I agree to contact my PCP to obtain authorization for my visit. If an authorization is not secured, or my plan declines coverage, I will assume responsibility for the charges incurred. Out of Network Plans: I acknowledge that it is my responsibility to verify whether Paramount Urgent Care is in-network with my insurance plain. I agree to pay any balance which results from out-of-network charges. Authorization to pay benefits to the physician: All insurance checks that may go directly to the patient MUST be signed over to Paramount Urgent Care for payment for services rendered. Failure to do this will results in the patient receiving a bill for services. I hereby authorize payment for medical services provided directly to Paramount Urgent Care. Patient Refunds: All patient refunds will be kept as a credit on the patient's account toward their next visit unless a refund request is initiated by the patient. The following criteria must be met prior to using a patient refund: There are not outstanding insurance claims or no outstanding patient balances on the account. Returned Check Policy: If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient of the Patient's Responsible Party will be responsible for the original check amount in addition to a $35.00 Service Charge. If no payment is received within 90 days, the patient's account will go to a collections agency and the patient will be discharged from the practice. Durable Medical Equipment: As we are an URGENT CARE facility, we have urgent care contracts with most major health insurance companies. In abiding with out contract guidelines, we CANNOT bill insurance companies for DME (Durable Medical Equipment) such as crutches, slings, braces, and extremity immobilizers. We carry these products as a convenience and they are available to our patients as an out-of-pocket expense. By signing, you acknowledge you understanding that any DME supplies cannot and will not be submitted to your insurance company by you or Paramount Urgent Care for reimbursement.