Welcome to AMS Urgent Care. We are pleased that you have chosen our practice for your medical needs. We ask that you carefully read and sign the following statement. We must emphasize that as your medical care provider, our relationship is with you and not your insurance carrier. As a courtesy, we will bill your insurance company for your visit. Your deductible and copay/co-insurance is due at the time of service. However, you are the sole responsible party for all charges incurred and guarantee payment. If we are contracted with your insurance company, we will accept assignment. Failure to provide current, accurate billing information will result in all charges for service becoming the sole responsibility of the patient/responsible party. You are expected to understand your benefits coverage and responsibilities.
We are preferred providers with the following insurance companies:
- Aetna Network (including EBMS, Meritain, GEHA, etc...)
- Blue Cross Blue Shield (including Federal Blue Cross)
- UnitedHealthcare
- Alaska State Medicaid
Self-Pay:
For patients not covered by insurance that are able to pay their bill in full by cash or credit card on the date of service we may be able to offer discounted rates on office visits, diagnostic testing, and durable medical equipment. All payment is due at the time services are rendered.
Worker’s Compensation:
If your injury is a work related, it is necessary to provide us with the correct Report of Occupational Injury Form. This form should be supplied by your employer and must contain the claim number and date of injury as well as the Worker’s Compensation Carrier your claim should be billed to. Without this information we will have to consider your visit as self-pay.
Automobile Accidents:
We can submit medical claims to personal auto insurance carriers for patient’s recently injured in a motor vehicle accident that has open and billable claim. The patient is required to provide the front desk with complete claim and billing information at the time of service. We do not deal with Third Party claims.
Medicare: We currently do not accept Medicare.
Medicaid: We do not accept out of state Medicaid. Any voluntary procedures, or procedures deemed by Medicaid as not medically necessary, will be the patient’s responsibility. Patients over the age of 18 will be responsible for their $3.00 co-pay at the time of visit.
Refunds: If an overpayment has occurred a refund check will be issued within 45 days from the final receipt of payment from your insurance company.
Any outstanding balances over 90 days old, will be turned over to a third-party collection agency.
We accept payment in the form of cash, credit/debit card, and cashier’s check. We do not accept personal checks.
In consideration of the services performed by AMS Urgent Care, you agree to abide by the terms of this financial statement.
By initaling below I understand the following:
- I understand that I am financially responsible for all charges incurred by my dependent or myself at the time of I agree to pay all amounts determined as patient responsibility as well as any fees associated with services rendered, including collections costs.
- I authorize my insurance company(s) to pay AMS Urgent Care for the charges that are filed by the clinic on my behalf.
- I understand AMS Urgent Care bills out as an office visit and not urgent care. This is a financial benefit to the majority of our patients. We will provide you with an explanation of your benefits and a cost estimate prior to being seen.
- In the event that payment is issued to me by my insurance company for treatment/services received at AMS Urgent Care any amount up to the balance on my account will be immediately remitted to AMS Urgent Care.
- I authorize AMS Urgent Care to release any medical information required by my insurance company, worker's compensation or auto insurance carrier for the processing of any medical claims on my behalf.
- I acknowledge that I have had the opportunity to ask for a copy of AMS Urgent Care Notice of Privacy Practices whic describes how my medical information may be used and disclosed.
- I have read and signed the AMS Urgent Care Financial Policy.