Financial Policy and Consent to Treatment

    Thank you for choosing Glacier Medical Associates as your health care provider. The following terms and conditions apply to the patient-provider relationship and our ability to provide healthcare to you. We cannot provide care to you without completion of this agreement.

 

Your Financial Responsibilities 

    You are ultimately responsible for the payment on your account. We file insurance claims for all reimbursable services to both your primary and secondary insurance carriers. You are responsible for copayments, co-insurance, deductibles and non-covered services. We accept paymentby cash,checks, Visa, MasterCard and Discover. You will receive statements from our office for account balances that are your responsibility; personal this balance is due within 30 days. If the patient portion of your account is not paid in a timely manner, collection efforts will be made. Any collection agency fees or other expenses incurred to collect the patient portion of your account will be at your expense. If your accountis sent to collections, you may be discharged as a patient. If you have a balance on your account at the time of service, payment in full or entering into a binding payment plan is required.

 

  

Health Insurance 

    It is your responsibility to understand your insurance coverage and benefits. We participate with most private insurance planshoweveritis your responsibility to provide us with your complete insurance information, and to bring your insurance card to all of your appointments. As a courtesy, we submit the claim on your behalf and make every effort to resolve any billing problems that arise. Your insurance requires that we collect your designated co-pay at the time of service. Please be prepared to pay your co-pay at each visit along with any outstanding balances. 

 

 Referrals and Pre-Authorization: It is your responsibility to obtain referrals and pre-authorization required by your insurance carrier and pay any charges should your insurance carrier deny benefits.

 

 

Workers Compensation 

    If you are injured through your employment, we will file your Worker's Compensation or Insurance Claim. You must provide us with a claim number, name of the carrier, date of injury, employer at the time of injury, and the part of the body injured to enable us to obtain properauthorizationto provide treatment and submit your claim. Without this information, or if the claim is denied, you are responsible for all charges and agree to pay them.

  

Accidents/Travelers

    We do NOT bill third party insurance for accidents, including, but not limited to Motor Vehicle Accidents (MVA); nor will we bill travelers/international policies including, but not limited to Canadian policies, foreign exchange student policies, etc. Patients are required to pay in full at time of service. We will provide the proper paperwork needed to submit to these insurances for reimbursement. 

 

 

Self Pay  

    If you do not have insurance, payment in full at the time of service is required. A 20% discount off regular office visit fees and 10% off any lab or procedures is offered for payment made at the time of service. If you cannot pay in full, you will need to meet with our Financial Services Department.

 

 

Disputed Claims/Visits

    All disputes regarding claims and visits to Glacier Medical Associates must be submitted in writing to either the Provider seen or the Operations Director.

 

 

Release of Protected Health Information 

    I authorize the release of protected healthcare information including bills and outstanding balances, and grant permission to the following individuals to speak to Glacier Medical Associates employees/contractors about my (or my child's, as applicable) protected healthcare information:

 

imMTrax Authorization

  I authorize my healthcare provider and public health agency to collect and enter my (or my child’s, as applicable)(initial) immunization records into the Department of Public and Human Services’ Immunization Information System (IIS). The IIS is aconfidential computer system that contains immunization records. Information in the registry may be released to a public healthagency as well as my healthcare providers and schools in order to comply with immunization requirements or continuity of care.I can revoke this authorization at any time by contacting my local health department.

 

 Additional Authorizations

• I authorize the release of any medical information necessary to process insurance claims.
• I authorize my insurance benefits to be paid directly to Glacier Medical Associates, PC.
• I authorize release of protected health information to my employer for work-related conditions 

 

I have read, understand and agree to the above Financial Policy and Consent to Treatment.