Patient Information

A new standard of care

Jonathon D. Brooks, D.C. CHIROPRACTOR

Ashley L. Eavenson, D.C. CHIROPRACTOR

Kevin Bell, M.D. FAMILY PRACTICE

Amanda Basham, APRN, FNP-BC FAMILY NURSE PRACTITIONER

Corey W. Voss, P.T. PHYSICAL THERAPIST

Tate Merten, CERTIFIED ATHLETIC TRAINER

 

By signing this form, I authorize you to obtain confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below. This is not for us to release records.

Release my protected health information to the person(s)/entity:

Name: Multicare Specialists

Street: 3986 Maryville Rd.

City: Granite City

State: IL

ZIP: 62040

3986 Maryville Road | Granite City, IL 62040

P 618.797.0618 F 618. 797.2243

The Release of Information will remain in effect until terminated by me in writing.

Financial Policy and Procedures - Multicare Specialists, S.C.

("MULTICARE") AND ITS HEALTHCARE PROVIDERS, INCLUDING ASHLEY EAVENSON D.C.; JONATHON BROOKS D.C.; KEVIN BELL M.D.; AMANDA BASHAM FNP-BC ; COREY VOSS P.T.; and TATE MERTEN CAT. ("PROVIDERS" YOU SHOULD READ THIS DOCUMENT CAREFULLY

Your signature on Multicares' Consent form authorizes the following:

• Multi-Care and Providers are hereby authorized to provide treatment and health care services to patient.
• To the fullest extent allowed by law, patient (or, if applicable, patient's representative) hereby assigns to Multicare Specialists any and all rights to payment from any one or more of Payment Sources for healthcare services now or hereafter provided to patient by Multicare Specialists or Providers, including (without limitation): (a) amounts payable under any private or public insurance or other benefit plan, including any group or individual accident, disability or health insurance policy or benefit plan or any automobile insurance policy; (b)compensation payable for such services under worker's compensation, occupational disease or other comparable laws; and (c) all proceeds of any claim or cause of action for personal injuries giving rise to such services.
• I authorize Multicare to release all pertinent medical information to my insurance carrier(s) or employer, in the case of a Workers Compensation claim, in order to process any and all claims.
• I understand that I will be charged $50 if I cancel an appointment less than 24-hours before an appointment and $100 for a no show fee if I do not show for an appointment without providing notice before the time of the appointment. My insurance will not be billed and I am fully responsible for these charges.  Exceptions to this policy may be granted at the discretion of Multicare.

• I understand I will be charged a $25 fee for returned checks for any reason.
• I understand I may be charged interest of an annual percentage rate of 9% for accounts more than 60 days past due
• I understand that should my account be referred to a collection agency for collections I will be responsible for all collection fees of 22% in addition to the amount referred to collections.
• If, after all your claims have been paid, the resulting balance is a credit of $5.00 or less, I authorize Multicare to write off this balance. Amounts greater than $5.00 will be refunded to me.
• I understand that payment, including co-payments and deductibles if applicable, is due on each date of service for the services rendered on that date, unless other arrangements have been made in writing. Unless otherwise agreed in writing, Multi-care is entitled to receive the standard rates set forth from time to time in its published fee schedule for the services provided to patient, plus all out of pocket expenses reasonably incurred for patient's care. Multi-care is entitled to receive the reasonable value of any services provided to patient that are not specifically listed in Multi-Care's published fee schedule.
• I understand that insurance coverage and verification is not a guarantee of payment. I agree that I am ultimately responsible for any balance due after my insurance has paid or denied my claim(s). I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHARGES IF THE INSURANCE COMPANY DENIES A CLAIM FOR ANY REASON INCLUDING STATING THAT IT IS INVESTIGATIONAL, EXPERIMENTAL, A PRE-EXISTING CONDITION, AUTO RELATED OR ACCIDENT-RELATED WHERE LIABILITY INSURANCE IS INVOLVED, OR ANY OTHER NON-COVERED SERVICE(S).
• I understand that if patient or patient's representative is entitled reimbursement or payment of amounts payable to Multicare Specialists or Providers by an insurance carrier, benefit plan or other third party payer ("Payment Sources"), Multicare Specialists is authorized to submit claims to Payment Sources on behalf of patient or patient's representative. However, except as otherwise required by law, Multicare Specialists may, in its sole discretion, elect (a) not to submit claims for all or any part of its services, (b) not to submit claims to one or more Payment Sources, and ( c) accept payment from any one or more of Payment Sources, without waiver or reduction of any right or claim to payment from patient or patient's representative or from any other source. Except to the extent otherwise allowed by law, patient (or, if applicable, patient's representative) shall remain primarily responsible for payment even if Multicare Specialists fails to submit claims to one or more potential Payment Sources or if Multicare Specialists is not paid in full by the Payment Sources to which claims are submitted.

Financial Policy Expectations:

• Please present your insurance card and photo ID at each appointment. Please share address, telephone number, email address, and/or insurance information updates any time a change occurs. We also take a photo of each patient to load internally on our system to help prevent identity fraud.
• Payment of your deductible and coinsurance will be required for your calculated portion of our fees, based on our contract with your insurance, in advance of any scheduled surgical procedures and diagnostic testing. Any balance remaining after your health plan pays its portion is your responsibility and payment for balance is due upon notification from our office. Any overpayment will be refunded directly to you.
• You may be asked to put a credit card on file, which will only be charged according to the terms you agree to when placing such card on file. By processing your insurance first, we will only charge you for your exact out-of-pocket responsibility.  You will receive notification containing a summary of charges and an estimate of what we believe you will owe.  After your insurance has processed your claim, you will receive a second notification informing you of the actual amount you owe and notifying you that your card will be charged. Your card will also be charged for return check fees, no-show, and late cancel fees following a missed appointment and/or returned check.
• Appointments will not be scheduled for patients with an outstanding balance. If your account is currently overdue, it must be brought up to good standing or you must have have an agreed upon and current payment plan on file before a new appointment will be scheduled.
• Your insurance is an agreement between you and your insurance company. As a courtesy to you, we will file your insurance claims for you if you assign benefits to the practice. If your insurance does not pay, we will look to you for payment of your balance in full.
• All health plans are not the same and do not cover the same services. If your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
• You are responsible for knowing and understanding your insurance benefits.
  Multicare reserves the right to not accept or bill an insurance company that we are not contracted with.
• You will be responsible for promptly responding to your insurance company to provide additional information they may request regarding your treatment, pre-existing conditions, accidents or other insurance coverage. Failure to respond in a timely manner may result in your account becoming due and payable, in full, by you.
• If your insurance plan requires prior authorization or referral from your primary care physician for each visit, this is your responsibility. IF YOU DO NOT HAVE THIS REFERRAL NUMBER AT THE TIME OF YOUR APPOINTMENT,YOUR BENEFITS MAY BE PAID AT A REDUCED RATE OR NOT PAID AT ALL AND YOU WILL BE RESPONSIBLE FOR THE CHARGES.

Workers Compensation Injuries:

• Multicare will bill any Workers Compensation insurance carrier or employer providing prior authorization.
• Multicare requires you to provide your group health insurance at time of scheduling regardless of the approval status of your Workers Compensation claim. In the event a service is provided and not covered under Workers Compensation, your group health insurance may be billed and you will be responsible for all deductibles, co-insurance, and copays.
• If a Workers Compensation carrier denies further authorization for your ongoing care Multicare may bill your group health insurance carrier. If you do not have group health coverage or have insurance that Multicare doesn’t accept you will be personally responsible for the charges.
• If your Workers Compensation claim is disputed and you have a case on file with the Illinois Workers Compensation Commission, Multicare may bill your group health and any remaining balance will be your responsibility once the case settles.

Liability, Auto Accident, and Personal Injury Injuries:

• Liability insurance information must be given at time of scheduling. If an attorney is involved you will be responsible for providing us with their name, address, and phone number.  We may bill your liability carrier as the primary payer.  Once the liability insurance has maxed, your group health carrier may be billed and you will be responsible for all remaining charges.

Payment Options:

• Payments can be made using cash, check, money order, Visa, Master Card, American Express, or Discover. Payments are due at time of statement.
  If payment cannot be made in full please contact our patient financial counselors at (618)797-0618 to set-up a formal payment plan.  If a formal payment plan is not established your account will be reviewed for collections.

 

Emergency

If patient has a medical emergency, patient ( or patient's representative, if applicable) should contact Multicare Specialists, but if unable to reach a Provider, should call 911 or go to the nearest emergency room.

Representative

If this document is signed by a representative, the representative represents and warrants that he has legal authority to do so. If patient is a minor or has been adjudicated as a disabled adult, the patient's parent (s) or guardian (s) assumes personal responsibility.

Multicare Specialists Financial Policy updated February 29, 2024

Authorized Representative Designation

I hereby designate, authorize and convey to Multicare Specialists, SC, to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action that I may have under such insurance policy and/or benefit plan, including but not limited to with respect to internal appeals or litigation; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as my Authorized Representative with respect to any claim, right, or cause of action under a benefit plan governed by the provisions of the Employee Retirement Income Security Act 1974 (ERISA"), as provided in 29 C.F.R. $2560.5031(b4 This authorization and designation is deemed to apply to any health care services that I have received from the Provider, or will receive in the future, and any related bills, expenses or claim for benefits now or in the future as a result of the services I receive from Provider, and, to the extent permissible under the law, authorizes Provider to seek on my behalf such benefits, claims, or reimbursement to which I am entitled, and any other applicable remedy, including fines or injunctive relief.

A photocopy of this Assignment/Authorization shall be as effective and valid as the original.

By signing this form, you acknowledge that you have received our “Notice of Privacy Practices” (the “Notice”). This Notice describes in detail how we might use or disclose your protected health information. The Notice also discusses your rights and our duties with respect to your protected health information. You have a right to review the Notice before signing this acknowledgment.

By signing this form, you further acknowledge that medical information collected at Multicare Specialists will be stored in a medical records system and kept securely in line with state and federal regulations.

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