GLACIER MEDICAL ASSOCIATES FINANCIAL POLICY AND CONSENT TO TREATMENT

Thank you for choosing Glacier Medical Associates as your health care provider. The following terms and conditions apply to the patient-provider relationship and our ability to provide healthcare to you. We cannot provide care to you without completion of this agreement. We use secure, HIPAA- compliant artificial intelligence tools to assist our providers in medical record documentation, and all notes are reviewed and approved by your provider. If you would like to opt out of use of this feature, please advise your provider before your appointment.

Your Financial Responsibilities

You are responsible for the payment on your account. We file insurance claims for all reimbursable services to both your primary and secondary insurance carriers so long as you provide accurate information regarding your insurer(s). If you have a balance on your account at the time of service, payment in full or entering into a binding payment plan is required. You are responsible for copayments, co-insurance, deductibles and non-covered services. We accept payment by cash, personal checks, Visa, MasterCard, Discover and American Express and require a credit card to remain on file for any outstanding patient responsibility balances that remain on your account. In providing us with your credit card information, you are giving Glacier Medical Associates, P.C. permission to automatically charge your credit card on file for your Visit at time of service. By signing this you authorize this agreement to remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request. If you do not have a credit card on file a deposit of $181 (for new patients) or $139 (for established patients) is required at time of service or a payment plan must be entered into.

PRIMARY CARE/SAME DAY VISITS: Your co-pay, if known, will be charged on your date of visit. If your co-pay is not readily obtainable, a charge of $181 (for new patients) or $139 (for established patients) will be made. If that amount is found to be in excess of your actual co-pay or deductible, you will be refunded the amount of excess once your insurer provides payment to us. If that amount is found to be less than your actual co-pay or deductible, your credit card on file will be charged the remaining amount due.

URGENT CARE VISIT: Unless you are an existing patient of Glacier Medical Associates, full charge of Urgent Care visits is due at time of the Urgent Care visit. Should insurance cover a portion or all of your Urgent Care visit, you will be issued a refund promptly after insurance pays.

OUTSTANDING BALANCE: You will receive an invoice for services for your visit. If you have an outstanding balance owed that is over 60 days past due, Glacier Medical Associates will make an attempt to notify you of the outstanding balance, and if by the final 60 day billing notice, we do not receive a response from you setting up a payment plan or your payment in full, at that time, any balance owed will be charged to your credit card. A copy of the charge will be sent by email or mailed to you. This in no way compromises your ability to dispute a charge or question your insurance company's determination of payment. On day 61 from the date of your visit, interest at the rate of 15% per annum will be applied to your outstanding balance.

MULTIPLE USERS: This card will only be authorized for the use of the credit card holder, his/her minor(s) children, or: (list any other authorized person(s I authorize Glacier Medical Associates, P.C. to charge the card I place on file consistent with this policy on my account.

COLLECTION EFFORTS: If you fail to pay your balance or any payments associated with a payment plan offered by Glacier Medical Associates, your account may be turned over to a collections agency for collections. In this event you agree to pay all costs of collection up to 40% of the outstanding balance, and any attorneys fees incurred in collecting the debt. In addition, if your account is sent to collections, you may be discharged as a patient.

CREDIT FOR OVERPAYMENTS: If you or your insurer overpay your balance by an amount of thirty dollars ($30.00) or less, the overpaid amount will be credited to your account for use toward future charges. If you do not anticipate future services, you may request a refund in writing. Refunds for overpayments exceeding thirty dollars ($30.00) will be automatically processed and issued in accordance with our refund policy.

Health Insurance

It is your responsibility to understand your insurance coverage and benefits. We participate with most private insurance plans however it is your responsibility to provide us with your complete and active insurance information, and to bring your insurance card to all of your appointments. We will attempt to verify your insurance eligibility at the time of check in. If we are unable to verify your insurance eligibility, you will be considered Self Pay. See below. As a courtesy, we submit the claim on your behalf and make every effort to resolve any billing problems that arise. Your insurance requires that we collect your designated co-pay at the time of service. Referrals and Pre-Authorization: It is your responsibility to obtain referrals and pre-authorization required by your insurance carrier and pay any charges should your insurance carrier deny benefits.

Workers Compensation

If you are injured through your employment, we will file your Worker's Compensation or Insurance Claim. You must provide us with a claim number, name of the carrier, date of injury, employer at the time of injury, and the part of the body injured to enable us to obtain proper authorization to provide treatment and submit your claim. Without this information, or if the claim is denied, you are responsible for all charges and agree to pay them.

Accidents/Travelers

We do NOT bill third party insurance for accidents, including, but not limited to Motor Vehicle Accidents (MVA); nor will we bill travelers/international policies including, but not limited to Canadian policies, foreign exchange student policies, etc. Patients are required to pay in full at time of service. We will provide the proper paperwork needed to submit to these insurances for reimbursement.

Self Pay

If you cannot supply complete and active insurance information at your visit you can be considered Self Pay. If you do not have insurance or are considered Self Pay, payment in full at the time of service is required. Discounted pricing is only available if payment is made in full at the time of service. Payment plans may also be available depending on the cost of the Visit. Patients authorizing recurring payment plans by verbal, written, or electronic agreement agree to allow Glacier Medical Associates to process their credit/debit card as scheduled.

Disputed Claims/Visits

All disputes regarding claims and visits to Glacier Medical Associates must be submitted in writing to: Glacier Medical Associates, 1111 Baker Ave, Whitefish, MT 59937.

Release of Protected Health Information

I authorize the release of protected healthcare information including bills and outstanding balances, and grant permission to the following individuals to speak to Glacier Medical Associates employees/contractors about my (or my child's, as applicable) protected healthcare information:

imMTrax Authorization

I authorize my healthcare provider and public health agency to collect and enter my (or my child's, as applicable) immunization records into the Department of Public and Human Services' Immunization Information System (IIS The IIS is a confidential computer system that contains immunization records. Information in the registry may be released to a public health agency as well as my healthcare providers and schools in order to comply with immunization requirements or continuity of care. I can revoke this authorization at any time by contacting my local health department.

 

Additional Authorizations:

I authorize the release of any medical information necessary to process insurance claims. / authorize my insurance benefits to be paid directly to Glacier Medical Associates, PC. I authorize release of protected health information to my employer for work-related conditions.

I have read, understand and agree to the above Financial Policy and Consent to Treatment.