We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practice’s financial policy. By signing below, you are agreeing to its terms.
- I am ultimately responsible for payment of charges for services I receive from ReMind Health Group including those covered by my insurance. As a convenience, ReMind Health Group will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.
- Some immediate payment may be expected at the time of service. This may include a co-pay and additional payment if ReMind Health Group determines that the cost of my visit will not be reimbursed by my insurance provider. This often happens if my deductible is not yet satisfied.
- ReMind Health Group may deny service or charge a service fee for failure to pay a co-pay or any outstanding balance at the time of service.
- It is my responsibility to provide my current address, telephone number, email address, and insurance information at each visit.
- I agree to provide ReMind Health Group and/or its designated payment agent with my debit/credit card information.
- I understand that my signature and payment information will be maintained on file for future use by the practice. The applicable payment card will be truncated and “tokenized” by the payment agent in order to help maintain the security of my payment information.
- I authorize ReMind Health Group and/or its designated payment agent to apply charges to my payment card for all amounts owed to ReMind Health Group, for medical visits, procedures or supplies, including (i) amounts agreed as part of a payment plan, (ii) copayments, (iii) coinsurance (after application of insurance proceeds), (iv) amounts not covered by insurance and/or (v) fees (if applicable) charged by the practice for failure to keep a scheduled appointment or provide timely notice of appointment cancellation.
- In the case of a patient balance that is not satisfied by a charge to my payment method or a payment plan, I may receive a monthly statement for any outstanding balance. I am responsible for paying this balance by its due date in order to avoid paying possible interest on the balance.
- I will not be provided with advance notice of payments authorized hereunder for transactions up to an amount specified by me. I will be provided with a courtesy notification prior to processing any payment in excess of such amount. Transaction receipts will be maintained in the patient file or will be emailed to me if I provide and maintain a valid email address.
- I authorize ReMind Health Group and/or its designated provider to send electronic account statements and invoices to my email address on file. I understand that it is my responsibility to maintain a current email address on file and that I will not receive a mailed copy of any electronic statement.
This authorization will remain in effect until I provide written notice of cancellation to ReMind Health Group. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify ReMind Health Group in writing of any changes in my payment or other information.