Financial Responsibility Agreement:
CCRC explained and I understand that CCRC offers a "Time of Service Discount" off the normal fees charged for services rendered if payment in full is made at the time services are rendered. By signing below, I choose not to take advantage of the discounted rates. Instead, I authorize CCRC to bill my insurance company (including workers compensation) the normal fees for service.
I also realize that there is a possibility that my insurance company may not pay some or part of fees for certain services rendered by CCRC. CCRC does not promise or guarantee that services rendered to me will be paid by my insurance company. I agree to pay for all charges for services rendered to me if my insurance company reduces or denies payment for any services provided to me by CCRC. Workers Compensation patients with an open claim are not responsible for charges and services rendered if they have an open and accepted Workers Compensation Claim. CCRC will not balance bill services provided to an accepted claim for a Workers Compensation patient who has been provided services by CCRC. Any services provided after a denial of my claim or closure of my claim (without authorized maintenance services) will be my responsibility to pay in full. I am required to notify CCRC if my claim is denied for any reason and contact them to cancel all services immediately. I am responsible to pay any services provided to me after denial of my Workers Compensation Claim.
I UNDERSTAND THAT I AM PERSONALLY FINANCIALLY RESPONSIBLE and obligated to pay, in full, THE ENTIRE BILLED AMOUNT, for any and all health care and/or professional services rendered to me WHETHER OR NOT MY INSURANCE PAYS any portion of the charges incurred by me. I understand that I am personally responsible for any charges, and unpaid portions of charges, not covered by insurance. I understand that amounts unpaid for over 90 days from the date services were rendered are past-due and subject to a monthly finance charge of 1.5% and an annual finance charge of 18%.
I understand and agree that if I fail to make any payments in a timely manner (including but not limited to the balances after insurance benefits and/or settlement proceeds have been received), after such default and upon referral to a collection agency, attorney, or small claims court by CCRC, I will be responsible for all costs of collection, including, but not limited to, collection agency fees up to 50% collection fees, court costs, and CCRC's attorney fees.