Consent to Bill Insurance

Patient's legal name

First NameLast Name

Patient's date of birth

Date

Parent or Legal Gaurdian Responsible for Clinic Bill

First NameLast Name

Responsible Party's phone number

Please enter a valid phone number.Format: (000) 000-0000.

Responsible party's email address

example@example.com

Our mission is to provide accessible, affordable care to youth.

All children can receive health care services at the clinic, regardless of their ability to pay or health insurance status.
You will never be sent to collections for your inability to pay a clinic bill.

There are options for patients who have difficulty paying the bill.

Any payment received is considered payment in full. OR
If you are unable to pay, your bill will be covered by the Rise Up Health Clinics Health Equity Fund.

Self-Pay Good Faith Estimates - click on the link to view care estimates.

Please acknowledge that you have read, understand, and consent to each section of our billing policy below.

Rows	Yes, I have read, understand, and consent.
Patient Responsibility: Health insurance will be billed after the patient’s visit. The clinic has contracts with the following: Blue Cross Blue Shield, Cigna, HealthPartners, Medica, Medicaid, UCare, UMR, and UnitedHealthcare. The patient is responsible for any and all co-payments, deductibles, and coinsurance. Any balances not covered by insurance become the responsibility of the patient. Patients are responsible for contacting their insurance company with any questions about any denied charges or out-of-pocket amounts that they owe.
Services Covered: It is the patient’s responsibility to determine which services are covered by insurance, including but not limited to, sports physicals, well-child checks, and preventative care. If laboratory testing is needed that cannot be completed in the clinic, specimens may be sent to Rise Up Health Clinics’ contracted laboratory for processing. The laboratory may bill the patient or their insurance directly for these services. Any charges for outside laboratory services are the responsibility of the patient or the responsible party. Rise Up Health Clinics does not determine or control the laboratory’s fees, billing practices, or payment rates.
Waiving Health Insurance: If the patient chooses not to use their health insurance (commercial plans only) for the clinic visit, they will be billed at the self-pay rate. They will need to sign a waiver in order to bypass submitting the claim to insurance. Good Faith Estimates will be available for patients, per the Good Faith Estimate policy. Patients who receive insurance through Minnesota Health Care Programs (MHCP) are not eligible to waive insurance.
Contracted Insurance Plans: If the insurance does not contract with RUHC or if all services provided by the clinic are not covered by the patient’s insurance, the patient will be financially responsible for any balance not covered by their insurance.The patient may: (a) Request a superbill that they can submit to insurance, OR (b) Elect not to use insurance and be billed at the self-pay rate
Incorrect Insurance Information: If the insurance information the patient submits to the clinic is incorrect, the patient will be responsible for payment of the visit and submit charges to the correct plan. The patient may: (a) Request a superbill that they can submit to insurance, OR (b) Elect not to use insurance and be billed at the self-pay rate
Uninsured: If the patient does not have health insurance, they will be billed at the self-pay rate.
Clinic Bills: The patient will receive their bill from the clinic for the amount that they owe following the clinic visit. If the patient is financially able, they will pay the bill within 30 days of the date the bill was issued. The clinic will send out bills via email or text weekly for 60 days. If needed, bills may be sent out via mail. Rise Up Health Clinics will issue bills for the health care provided at the clinic and at mobile vaccine clinics.
Receiving Bills: The patient may receive a Rise Up Health Clinics bill for a variety of reasons. For example: (a) The patient may have a copay, coinsurance, or deductible. (b) The patient may not have health insurance, or RUHC may not have the patient’s current insurance information on file. (c) The service the patient received may not be covered by their insurance. (d) The patient may have received care outside of their provider. (e) The patient may not have obtained a required referral from their primary care provider. Clinic bills will be emailed and sent via text. Message and data rates may apply. You may opt out of text messages at any time by emailing Billing@RiseUpHealthClinics.org. Bills will be emailed from pm-practicefusion@practicefusion.com.
Consent: I consent to recieving emails and text messages about my clinic bill, appointments, and the clinic. I understand the patient will receive health services regardless of the ability to pay or health insurance status. If I need to make billing changes or questions, I will email Billing@RiseUpHealthClinics.org. I acknowledge that this billing consent will remain in effect for one year; or, until the student reaches 18 or completes their high school career; or until changes by me (parent/guardian) are made in writing.

If you receive a bill, which option best desribes you? Your answer will not affect the care the patient receives.

Please upload a photo of the FRONT side of your insurance card.

Please upload a photo of the BACK side of your insurance card.

Insurance Provider (for example, BCBS, HealthPartners, UCare)

Group number

Policy/Member ID number

Policy effective date

Policyholder's name

Policyholder's date of birth

I acknowledge that this billing consent will remain in effect for one year; or, until the student reaches 18 or completes their high school career; or until changes by me (parent/guardian) are made in writing.

Write in the date you would like your insurance to be billed effective from (for example: my last clinic visit 9/1/2026)

Parent or Guardian Signature (or patient if 18 years+)

Patient Consent to Bill Insurance

Responsible Party

Billing Information