Thank you for choosing us as your healthcare provider. We are committed to excellent patient care. The following is an explanation of our Financial Policy and Agreement, which you must read and sign prior to any current and future medical evaluation or treatment in this office. All patients must complete all intake forms and provide copies of their insurance card and driver’s license prior to seeing the provider.
- Each patient is responsible for his or her own bill, unless a minor, then the parent(s) are financially responsible.
- Payment of all insurance co-payments and deductibles/coinsurance is required at the time medical services are rendered. If payment is not collected at the time of service, the appointment may be rescheduled.
- Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy, this office will submit bills to your insurance carrier. To facilitate claims processing, you must provide all insurance policy information and changes to our office immediately. Your bill is your responsibility whether your insurance company pays or not. At times, you may need to contact your insurance carrier regarding slow or non- payment of your insurance claim.
- You are responsible for knowing what your insurance plan benefits are under your health insurance plan. Any services provided, but not covered by your insura nce company, as an in-network, will be your responsibility to pay.
- If your insurance company has not paid for your services within 90 days, you are responsible for paying the outstanding balance without further delay.
- Monthly payments are required on all accounts with outstanding balances. Payment plans may be set up for balances over $100.00. Payment plans are to be paid in full within four installments. A credit card will be kept on file for payment towards balances. Your signature below authorizes payments to be withdrawn and applied toward any outstanding balances. A monthly finance charge of 11/2% monthly (18% annual rate) will be charged to the amount not paid after 30 days. By signing below, you a gree to pa y collection costs and/or attorney’s fees on any delinquent balance, if referred to any agency or attorney for collection or suit as allowed by Utah Code Annotated, Sec. 12-1-11.
- A $35.00 fee will be charged on all returned checks. Cash or Debit card payments will be required for future payments.
- Patients who fail to appear for their scheduled appointments may be charged a fee of $ 75.00 unless the patient cancels the appointment at least 24 hours before the scheduled appointment time.
- If you arrive more than 10 minutes late for an ppointment, we reserves the right to cancel the appointment.
- If your injuries were sustained in an automobile accident it is your responsibility to provide us with Automobile insurance and policy number as well as your private health insurance information. If your PIP is exhausted, we will bill private health insurance. If they do not pay, we must have a medical lien on file within 30 days of your first statement and any unpaid balances are paid in full immediately upon settlement; otherwise, your account is subject to collection action.
USUAL AND CUSTOMARY RATES
Our rates for medical services reflect the usual and customary rates in the community. Unless we have accepted an alternate fee schedule from your insurance company, you are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates for medical services.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize this office to release all information concerning my medical treatment to my insurance carriers and to request referring providers (if any). I also acknowledge that I have been provided with a copy of the HIPAA Policies and Practices.
AUTHORIZATION TO PAY BENEFITS
I further authorize and direct said agency, attorney, or Insurance Company to pay from the proceeds of benefits of any recovery of insurance payments in my case, directly to the providers of this office, for their professional services rendered . I understand this in no way relieves me of my personal responsibility for paying my provider when a statement is rendered. It is understood that the signing of this form does not prohibit customary monthly billings.
LIST OF PLANS/CARRIER WE DON’T PARTICIPATE WITH
The following is a list of plans and carriers which our providers are not participating in:
- Regence Blue Cross Individua l a nd Fa mily a nd Foca l Point
- Optum (Life1)
- Select Hea lth Signa ture
- Cigna Loca l Plus, a nd Sure Fit
- PEHP ca pita l pla n.
- ELITE MEDICAL, LLC (801) 569-1973 www.e-medonline.com
- Deseret Select.