Registration History

INSURANCE ASSIGNMENT AND RELEASE

I certify that I have insurance coverage with

 

and assign directly to Life Elevated Psychiatry, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Life Elevated Psychiatry, may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date signed below.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the Dr. and is not a substitute for payment. Some insurance companies pay only a portion of the costs. It is your responsibility to pay deductible, co-insurance, copay or any balance not paid by your insurance. In the event the account is turned over for collections, the collections fees and/or legal fees, including attorney's fees up to 40% shall be your responsibility. All copays are due at the time of service.

This Notice describes Life Elevated Psychiatry practices and that of:

• Any health care professional or billing staff authorized to use or disclose protected health information.
• All departments and units of Life Elevated, and the operations we outsource to certain of our business partners.
• All employees, staff and other Life Elevated Psychiatry personnel.

All these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or operations purposes described in this Notice.

We understand that medical information about you and your health is personal. We are committed to protecting your medical information. You may receive a record of the care and services you receive at Life Elevated. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care used, modified or generated by Life Elevated. Your hospital may have different policies or notices regarding the hospital's use and disclosure of you medical information created in the hospital. We refer to Protected Health Information herein as PHI.

Our Notice of Privacy Practices provides detailed information about how we may use and disclose protected health information about you. As a patient/covered individual you have a right to a copy of that Notice. You may obtain a full copy of the Notice from our

Please acknowledge your receipt of this notification by signing below and returning it to the receptionist. Thank you.

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.

Your initial is REQUIRED below:

____ Due to the NO SURPRISE ACT going into effect January 1,2022, it is required that providers disclose to their patients any carrier or plan or if you have no insurance (Self Pay) that they are not participating in. It is the patient’s choice to continue to see the provider with the understanding that the services will be processed as out of network (OON) and will cause higher out of pocket costs to you. By choosing to continue to seek treatment by one of our providers, you will be required to sign a Good Faith Estimate (GFE) which will outline your financial responsibilities for each date of service you schedule with our provider(s). You will receive a copy and explanation of the GFE within 72 hours of your appointment upon which your out-of-pocket liability will be due. If payment is not received prior to your appointment, your appointment will need to be rescheduled. For further information about the No Surprise Act, please visit, https://www.cms.gov/nosurprises.

*No Surprise Act does not pertain to Medicare, Medicaid, or Tricare.

Article 1 Dispute Resolution

By signing this Agreement ("Agreement") we are agreeing to resolve any Claim for medical malpractice by the dispute resolution process described in this Agreement. Under this Agreement, you can pursue your Claim and seek damages, but you are waiving your right to have it decided by a judge or jury.

Article 2 Definitions:

1. The term "we," "parties" or "us" means you, (the Patient), and the Provider.
   
2. The term "Claim" means one or more Malpractice Actions defined in the Utah Health Care MalpracticeAct (Utah Code 78-14-3(15 Each party may use any legal process to resolve non-medical malpractice claims.
3. The term "Provider" means the physician, group or clinic and their employees, partners, associates, agents, successors and estates.
4. The term "Patient" or "you" means:

(1) you and any person who makes a Claim for care given to YOU, such as your      heirs, your spouse, children, parents or legal representatives, AND        

(2) your unborn child or newborn child for care provided during the 12 months immediately following the date you sign this Agreement, or any person who makes a Claim for care given to that unborn or newborn child.

Article 3 Dispute Resolution Options

1. Methods Available for Dispute Resolution. We agree to resolve any Claim by:
(1) using non-binding mediation (each of us will bear one-half of the costs);

(2) using non-binding mediation (each of us will bear one-half of the costs); OR          

(3) using binding arbitration as described in this Agreement.        

You may choose to use any or all of these methods to resolve your Claim.

1. Legal Counsel. Each of us may choose to be represented by legal counsel during any stage of the dispute resolution process, but each of us will pay the fees and costs of our own attorney.
2. Arbitration - Final Resolution. If working with the Provider or using non-binding mediation does not resolve your Claim, we agree that your Claim will be resolved through binding arbitration. We both agree that the decision reached in binding arbitration will be final.

 

Article 4 How to Arbitrate a Claim

1.  Notice. To make a Claim under this Agreement, mail a written notice to the Provider by certified mail that briefly describes the nature of your Claim (the "Notice" If the Notice is sent to the Provider by certified mail it will suspend (toll) the applicable statute of limitations during the dispute resolution process described in this Agreement.
2. Arbitrators. Within 30 days of receiving the Notice, the Provider will contact you. If you and the Provider cannot resolve the Claim by working together or through mediation, we will start the process of choosing arbitrators. There will be three arbitrators, unless we agree that a single arbitrator may resolve the Claim. 

   (1) Appointed Arbitrators. You will appoint an arbitrator of your choosing and all Providers will jointly appoint an arbitrator of their choosing.

   (2) Jointly-Selected Arbitrator. You and the Provider(s) will then jointly appoint an arbitrator (the "Jointly-Selected Arbitrator" If you and the Provider(s) cannot agree upon a Jointly-Selected Arbitrator, the arbitrators appointed by each of the parties will choose the Jointly-Selected Arbitrator from a list of individuals approved as arbitrators by the state or federal courts of Utah. If the arbitrators cannot agree on a Jointly-Selected Arbitrator, either or both of us may request that a Utah court select an individual from the lists described above. Each party will pay their own fees and costs in such an action. The Jointly- Selected Arbitrator will preside over the arbitration hearing and have all other powers of an arbitrator as set forth in the Utah Uniform Arbitration Act.

 

C.      Arbitration Expenses. You will pay the fees and costs of the arbitrator you appoint and the Provider(s) will pay the fees and costs of the arbitrator the Provider(s) appoints. Each of us will also pay one-half of the fees and expenses of the Jointly-Selected Arbitrator and any other expenses of the arbitration panel.

D.     Final and Binding Decision. A majority of the three arbitrators will make a final decision on the Claim. The decision shall be consistent with the Utah Uniform Arbitration Act.

E.     All Claims May be Joined. Any person or entity that could be appropriately named in a court proceeding ("Joined Party") is entitled to participate in this arbitration as long as that person or entity agrees to be bound by the arbitration decision ("Joinder" Joinder may also include Claims against persons or entities that provided care priorto the signing date of this Agreement. A "Joined Party" does not participate in the selection of the arbitrators but is considered a "Provider" for all other purposes of this Agreement.

 

Article 5 Liability and Damages May Be Arbitrated Separately

At the request of either party, the issues of liability and damages will be arbitrated separately. If the arbitration panel finds liability,the parties may agree to either continue to arbitrate damages with the initial panel or either party may cause that a second panel be selected for considering damages. However, if a second panel is selected, the Jointly Selected arbitrator will remain the same and will continue to preside over the arbitration unless the parties agree otherwise.

Article 6 Venue / Governing Law

The arbitration hearings will be held in a place agreed to by the parties. If the parties cannot agree, the hearings will be held in Salt Lake City, Utah. Arbitration proceedings are private and shall be kept confidential. The provisions of the Utah Uniform Arbitration Act and the Federal Arbitration Act govern this Agreement. We hereby waive the prelitigation panel review requirements. The arbitrators will apportion fault to all persons or entities that contributed to the injury claimed by the Patient, whether or not those persons or entities are parties to the arbitration.

Article 7 Term / Rescission / Termination

1. Term. This Agreement is binding on both of us for one year from the date you sign it unless you rescind it. If it is not rescinded, it will automatically renew every year unless either party notifies the other in writing of a decision to terminate it.
2. Rescission. You may rescind this Agreement within 10 days of signing it by sending written notice by registered or certified mail to the Provider. The effective date of the rescission notice will be the date the rescission is postmarked. If not rescinded, this Agreement will govern all medical services received by the Patient from Provider after the date of signing, except in the case of a Joined Party that provided care prior to the signing of this agreement (see Article 4(E)).
3. Termination. If the Agreement has not been rescinded, either party may still terminate it at any time, but termination will not take effect until the next anniversary of the signing of the Agreement. To terminate this Agreement, send written notice by registered or certified mail to the Provider. This Agreement applies to any Claim that arises while it is in effect, even if you file a Claim or request arbitration after the Agreement has been terminated.

Article 8 Severability If any part of this Agreement is held to be invalid or unenforceable, the remaining provisions will remain in full forceand will not be affected by the invalidity of any other provision.

Article 9 Acknowledgement of Written Explanation of Arbitration

I have received a written explanation of the terms of this Agreement and I have been verbally encouraged to read it andthis Agreement. I have had the right to ask questions, I have been verbally encouraged to ask any questions, and I have hadall my questions answered. I understand that any Claim I might have must be resolved through the dispute resolution process inthisAgreement instead of having them heard by a judge or jury. I understand the role of the arbitrators and the manner in which they are selected. I understand the responsibility for arbitration related costs. I understand that this Agreement renews each year unless cancelled before the renewal date. I understand that I can decline to enter into the Agreementand still receive health care. I understand that I can rescind this Agreement within 10 days of signing it.

Article 10 Receipt of Copy I have received a copy of this document.